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MONOGRAPHS OF 

THE ROCKEFELLER INSTITUTE 

FOR MEDICAL RESEARCH 

No. 11 October 15, 1919 



TOTAL DIETARY REGULATION IN THE TREATMENT 
OF DIABETES 

By 

FREDERICK M. ALLEN, M.D., EDGAR STILLMAN, M.D., and 
REGINALD FITZ, M.D. 




NEW YORK 

The Rockefeller Institute for Medical Research 

1919 



LIBRARY 

NEW YORK STATE VETERINARY COLLEGE 

ITHACA, N. Y. 





3 1924 104 225 283 




Cornell University 
Library 



The original of tiiis book is in 
tine Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://www.archive.org/details/cu31924104225283 



MONOGRAPH No. 11 



TOTAL DIETARY REGULA' 
TION IN THE TREATMENT 
OF DIABETES. 



BY 



FREDERICK M. ALLEN, M.D., EDGAR STILLMAN, M.D., AND 
REGINALD FITZ, M.D. 




NEW YORK 
The rockefeller institute for medical research 

igi9 



|<H^ '■4-4-L 







PREFACE. 

This monograph comprises the records of seventy-six out of one 
hundred diabetic patients treated in the Hospital of The Rockefeller 
Institute, and chapters on certain aspects of the clinical research. 
The opening chapter was written as an introduction to the publication 
as originally planned, and was to have been followed by chapters deal- 
ing respectively with carbohydrate, protein, fat, total metabolism, 
acidosis, pathology, etc., with combined animal and clinical experi- 
ments, and a fairly complete survey of the hterature. Certain events, 
however, have interfered with this program and publication is proceed- 
ing in reverse order, the clinical part now appearing in advance of the 
reports of the animal experiments. The latter will shortly appear in 
a series of journal articles. Most of the collected bibliography, except 
that pertaining to the history of the subject (Introduction) , has like- 
wise been omitted from the present monograph. Reports by members 
of the staff of this hospital, concerning chemical aspects of the dia- 
betic problem or methods employed, are included in the bibUography 
of Chapter I under the names of CuUen, Fitz, Pahner, Stilhnan, and 
Van Slyke. The cooperation and courtesy received so liberally from 
outside the Institute are acknowledged in the text as far as possible. 

When publication is complete, it will be seen that the conclusions 
rest upon a unified research composed of three principal interde- 
pendent parts. One of these has compared clinical diabetes in its 
principal characteristics with that produced experimentally in various 
species of animals, and has shown that the latter, in the absence of 
spontaneous tendencies, is influenced by changes in the total metab- 
olism and body weight, and not by carbohydrate ingestion alone. 
The second is the present chnical investigation, in which this principle 
has been applied to patients. The third is a pathological study, not 
yet finished, but included here in the form of a preliminary outline 
because of its' important relation to the problems of treatment. 



IV PREFACE 

A therapeutic advance should mean a raising of the general level of 
chnical results, in the sense of saving hfe in some proportion of cases 
formerly fatal, and prolonging it to greater or less extent in the more 
hopeless cases. Expectations of an actual cure, in the sense of a 
restoration of the normal power of food assimilation, will necessarily 
be disappointed in most cases under any dietetic treatment, and the 
need of some more potent therapy than diet is a keen stimulus to 
research. The method of treatment here presented has never been 
proposed as such a cure, and ameHoration of the existing condition 
and preservation of hfe and usefulness at the price of continued pre- 
cautions have been recognized as the limit of present attainment in 
diabetes. As set forth in the text, the mistakes incident to the 
development of a new method have reduced the general results below 
the theoretical ideal. The severity of the test is evident, however, 
from the grave character of the cases chosen and their known fate 
under former practice. The experience as a whole is believed to sus- 
tain both the theoretical principle and its practical value for the 
dietetic treatment of diabetes. 



MONOGRAPH OP THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH, 

NO. 11, October 15, 1919. 



TOTAL DIETARY REGULATION IN THE TREATMENT OF 

DIABETES. 

By FREDERICK M. ALLEN, M.D., EDGAR STILLMAN, M.D., and REGINALD 

FITZ, M.D. 

{From the Hospital of The Rockefeller Institute for Medical Research.) 
(Received for publication, April 29, 1918.) 

CONTENTS. 

Chapter I. Introduction. History 1 

The Ancient Period (to 1675 A. D.) 2 

The Second or Diagnostic Period (1675-1796) 8 

The Period of Empiric Treatment (1796-1840-50) 14 

The Modern or Experimental Period 21 

Bibliography 65 

Chapter II. General Plan of Treatment 79 

General Measures 80 

Routine Care of Patients 80 

Ward Regulations and Clinical Remarks 82 

Treatment up to Cessation of Glycosuria in Simple Cases 90 

Emergencies and Complications 98 

Acidosis 98 

Infectious and Surgical Complications 115 

Treatment following Cessation of Glycosuria 125 

Ideals of Diet and Laboratory Control 137 

Practical Management of Diets 148 

Organization 148 

Equipment 149 

Special Features of Maintenance Diet 151 

General Scheme and Specimen Diets 161 

Food Tables 173 

Chapter III. Case Records and Charts 177 

Chapter IV. Pancreas Feeding 461 

Chapter V. Exercise 468 

Immediate Effect of Exercise on Blood Sugar 468 

The Effect on Carbohydrate Tolerance and Glycosuria 488 

The Use of Exercise in Various Classes of Patients 491 

The More Permanent Effects of Exercise upon Assimilation and the 
Diabetic Condition 495 

V 



VI CONTENTS 

Chapter VI. The Influence of Fat in the Diet 500 

Influence of Body Weight 501 

Influence of Total Diet 502 

Chapter VII. Results — Prognosis 532 

Severity of Cases 532 

Cases and Results by Decades 536 

Causes of Death 557 

Treatment of Coma 558 

Infections 562 

Reasons for Failure in Treatment 567 

Severity of the Treatment 575 

Prognosis 577 

" Spontaneous Downward Progress" 581 

General Summary 594 

Chapter VIII. Etiology and Pathology 596 

Etiology 596 

Carbohydrate or Dietary Excess 596 

Obesity 598 

Pluriglandular Disorders 599 

Constitutional Defects 600 

Heredity. . . . : 600 

Nervous Causes 605 

Trauma 607 

Infection and Inflammation 608 

Pathology 615 

Changes Causing Diabetes 615 

Changes Due to Diabetes 620 

Clinical Application 631 

Chnical Etiology 631 

Anatomic Diagnosis 636 

Relation to Treatment 642 

Conclusions 646 



CHAPTER I. 

INTRODUCTION. 

History. 

Understanding of the existing state of a subject is generally aided 
by knowledge of its history. Aside from what is given in text-books, 
notably those of Cantani and Lepine, the early history of diabetes has 
been written briefly by Hirsch, but most exhaustively by Salomon, to 
whom reference may be made for exact citations of most of the ancient 
and medieval works here quoted. A previous publication^ has re- 
viewed some of the theoretical and experimental features of the sub- 
ject. The following account aims to trace the development of clinical 
knowledge and treatment of diabetes, taking note of theories and ex- 
periments only as they have influenced practice. The attempt has 
been made to present the true and significant, assigning credit to the 
successive workers as accurately as the recorded evidence permits. 

It is convenient, following approximately Cantani, to divide the 
history of diabetes into four periods. The first extends from the most 
ancient times to the discovery of the sweetness of the urine by Willis 
in 1675, which ushered in the second or diagnostic period. The third 
period, that of empiric treatment, began with Rollo in 1796. The 
fourth, or modern period, was inaugurated in the decade 1840 to 1850, 
the most prominent founders being Bernard and Bouchardat. With 
all its imperfections, this yet merits the name of the experimental 
and scientific period. 

»Men(l). 



I. The Ancient Period (to 1675 A. D.). 

"In the papyrus Ebers, which is a copy of an Egyptian medical 
compilation already old in the time of Moses, there is mention of 
polyuria, and it is hard to conceive that such a marked departure from 
health could at any time have escaped observation" (Saundby). For 
explanation of the relatively late period of human history at which 
diabetes was first clearly recognized and described, we need not as- 
sume the absence or rarity of the disease among the ancients, but must 
rather consider the impossibility of their diagnosing mild cases, the 
natural confusion of severe cases with chronic nephritis and various 
forms of pol3mria and with tuberculosis and other wasting conditions, 
and the further difl&culties presented by the various complications. 
The differences between cases have puzzled even modern physicians 
to such an extent that the existence of diabetes as a unified entity 
rather than a disjointed symptom-complex has been disputed up to 
very recent years. 

Hippocrates (460-377 B.C.) made no mention of any condition 
clearly recognizable as diabetes. A notion concerning the quantity of 
urine, in a passage translated by Richardson from the third book of 
the Epidemics,^ is like that of Celsus, but the first known recognition 
of diabetes occurred at about the height of the Roman power. 

Aulus Cornelius Celsus (30 B.C.-SO A.D.) wrote as follows:' 
''When urine, even in excess of the drink, and flowing forth without 

^ "In some cases the urine was not in proportion to the drink administered, but 
greatly in excess ; and the badness of the urine was great, for it had not the proper 
thickness nor concoction nor purged properly; for in many cases purgings by the 
bladder indicated favorably, but in the greatest number they indicated a melting 
of the body, disorder of the bowels, pain and a want of crisis." 

'Lib. iv, cap. xx, 2; ref. by Salomon: "At cum urina super potionum modum 
etiam sine dolore profluens maciem at periculum facit, si tenuis est, opus est 
exercitatione et frictione, maximeque in sole, vel ad ignem; balneum rarum esse 
debet, nequelonga in eo mora; cibus comprimens; vinum austerum meracvun, per 
aestatem frigidum, per hiemem egelidum; sed tantum, quantum minimum sit. 
Infima alvus quoque vel ducenda, vel lacte purgenda est. Si crassa urina est 

2 



HISTORY 3 

pain, causes emaciation and danger, if it is thin, exercise and massage 
are indicated, especially in the sun or before a fire; the bath should be 
infrequent, nor should one linger long in it; the food should be con- 
stipating, the wine sour and unmixed, in summer cold, in winter luke- 
warm; but everything in smallest possible quantity. The bowels also 
should be moved by enema, or purged with milk. If the urine is 
thick, both exercise and massage should be more vigorous; one should 
stay longer in the bath; the food should be light, the wine likewise. 
In each disease, all things should be avoided that are accustomed to 
increase urine." 

In this compressed passage, Celsus gives the first description of 
diabetes, introduces an error (fluid output greater than intake) 
destined to endure eighteen centuries, and touches some modern treat- 
ment. It is not known to what extent this knowledge was original 
with Celsus or handed down by predecessors. At any rate, the recog- 
nition of the disease was so new that it had not yet received a name. 

Aretaeus of Cappadocia (30-90 A.D.), living under the emperor 
Nero, and writing in Ionian Greek, was the second to describe dia- 
betes, and the first known to have called it by the name {ha^alvav, to 
run through; Sta/S^rijs, a siphon). In a passage translated by Schn6e*, 

vehementior esse debet et exercitatio et frictio; longior in balneo mora; cibisopus 
est tenuis; vinum idem. In utroque morbo vitanda omnia sunt, quae urinam 
movere consuerunt." 

^ "Diabetes is a strange disease, which fortunately is not very frequent. It con- 
sists in the flesh and bones running together into urine. It is like dropsy in that 
the cause of both is moisture and coldness, but in diabetes the moisture escapes 
through the kidneys and bladder. The patients urinate unceasingly; the urine 
keeps running like a rivulet. The Ulness develops very slowly. Its final outcome 
is death. The emaciation increases very rapidly, so that the existence of the 
patients is a sad and painful one. The patients are tortured by an unquenchable 
thirst; they never cease drinking and urinating, and the quantity of the urine ex- 
ceeds that of the liquid imbibed. Neither is there any use in trying to prevent the 
patient froni urinating and from drinking; for if he abstains only a short time from 
drinking his mouth becomes parched, and he feels as if a consximing fire were raging 
in his bowels. The patient is tortured in a terrible manner by thirst. If he re- 
tains the urine, the hips, loins, and testicles begin to swell; the swelling subsides as 
soon as he passes the urine. When the illness begins, the mouth begins to be 
parched, and the saliva is white and frothy. A sensation of heat and cold extends 
down into the bladder as the illness progresses; and as it progresses still more there 



4 CHAPTER I 

Aretaeus outlines some of the principal symptoms, the progressive 
course, and the fatal prognosis. He anticipates modem conceptions 
of a failure of assimilation, conversion of tissue into urinary products, 
and possible origin of some cases in acute infections. He was retro- 
grade in treatment, for he advised a non-irritating diet of milk and 
carbohydrates, andhiera, nardum, mastix, and theriak (opium? sugar?) 
as drugs. He is commonly credited with being the first to regard 
diabetes as a disease of the stomach; but his vague notion of a dis- 
order akin to ascites hardly entitles him to a claim upon this false idea 
which was productive of so much truth in the period from Rollo to 
Cantani. 

Claudius Galenus (born 131 A.D.) saw two patients and introduced 
two ideas: first, that diabetes is a weakness of the kidneys, which can- 
not hold back water and also are thirsty for fluid ; second, that the urine 
consists of the unchanged drink. Galen's great authority maintained 
these errors for about 1500 years, and retarded progress in the knowl- 
edge of diabetes. 

Chronological order here shifts the narrative to the Far East. 
According to Iwai, the first oriental description of diabetes was given 
in the year 200 by Tchang Tchong-king, perhaps the greatest of 
Chinese physicians. "There is a disease called 'the disease of thirst,' 
in which poljoiria is the characteristic symptom. One may drink as 
much as ten Hters per day, which is recovered in the urine." A 
Chinese medical work of about the year 600 classifies four supposed 
groups of cases, and notes the s}Tnptoms of polyphagia, polydipsia, 
and pol5Tiria. Still a later work mentions furunculosis. About the 
fifteenth century, diabetes was attributed to wine and high living. 

is a consuming heat in the bowels. The integuments of the abdomen become 
wrinkled, and the whole body wastes away. The secretion of the urine becomes 
more copious, and the thirst increases more and more. The disease was called 
diabetes, as though it were a siphon, because it converts the human body into a 
pipe for the transflux of liquid humors. Now, since the patient goes on drinking 
and urinating, while only the smallest portion of what he drinks is assimilated by 
the body, life naturally cannot be preserved very long, for a portion of the flesh 
also is excreted through the urine. The cause of the disease may be that some 
malignity has been left in the system by some acute malady, which afterward is 
developed into this disease. It is possible also that it is caused by a poison con- 
tained in the kidneys or bladder, or by the bite of the thirst-adder or dipsas." 



HISTORY 5 

Among the Japanese, Kagawa Shu-An described the s)m!iptoms of 
diabetes as frequency of urination, with urine exceeding the drink in 
quantity, pale color and sugar taste of the urine^ and insatiable hunger 
and thirst. Homma Gencho in 1864 noted the typical symptoms, the 
death from emaciation, and the urine so sweet as to attract dogs. 
These accounts show obvious European influence, and the Japanese 
seem to have made no original contributions. According to Iwai, this 
may be explained by the rarity and mildness of diabetes among them. 

In Europe, iEtius of Amida (550 A.D.) accepted the Galenic doc- 
trines, but introduced into therapy three measures long used there- 
after; viz., bleeding, emetics, and narcotics. According to a passage 
quoted from ^tius by Donkin ( (1), p. 128), Archigenes in the second 
century was the first to use opium for diabetes. 

The earliest mention of the sweetness of diabetic urine is contained 
in the Ayur Veda of Susruta, dating from the sixth century. The 
disease bore the distinctive name of Madhumeha or honey-urine.^ 
Thus the most prominent clinical feature, and one of the most widely 
supported modern hypotheses concerning etiology, received their first 
mention in India. But Hindu medicine failed to advance beyond this 
beginning, and exerted no influence on progress elsewhere. 

The Arabs are credited with nothing but passing on classical learn- 
ing to modern Europe, and their two greatest physicians, Rhazes 
(850-992 A.D.) and Avicenna (980-1037 A.D.) are rated by Salomon 
as barren followers of Galen, whose observations serve only for evi- 
dence that diabetes existed among the Arabs. But Dinguizli has 
translated some passages which seem to establish an advanced posi- 
tion for Avicenna. In these passages, he remarks that diabetes is 
generally primary, but sometimes secondary to some other disease. 
He describes the irregular appetite, the great thirst, the urine equal to 
the drink, the nervous exhaustion, and the loss of sexual function and 
of ability to work. In suggesting that the renal weakness is due to a 
relaxed state of the nerve-plexus of the kidney, he propounds the first 

* A translation by Chunder Bose is as follows: "Madhumeha is a disease which 
the rich principally suffer from, and is brought on by their overindulgence in rice, 
flour, and sugar. The patient feels weak and emaciated, and complains of frequent 
micturition, thirst, and prostration. Ants flock round his urine. Carbuncles and 
phthisis are its frequent comphcations." For other quotations, see Christie. 



CHAPTER I 



nervous hypothesis of diabetes. "In this disease, the liver is affected, 
and its r61e of provider of heat is disturbed in consequence of the 
exaggeration of organic combustions. .... The relations 
between the kidney and hver become irregular, in that the kidney 
attracts the humors from the liver in greater quantity than it is 
able to retain them." Having thus enriched the theory of the sub- 
ject with the r61e of the liver, increased metabolism, and balance 
between organs, he proceeds to give the first description of diabetic 
gangrene, which spreads and causes death. Such inflammations are 
due to retarded circulation in the limb, or to decomposition of the 
blood, which results from diminution of water in the blood. Further- 
more, the urine on evaporation leaves "a residue particularly scanty, 
of a sweet taste like honey, and resembling particles of bran." If 
this account proves authentic, it raises Avicenna to the rank of a 
clinical genius; but the second period of diabetes still begins with 
WilUs, because only the latter's observation influenced the further 
development of the subject. Avicenna's treatment consisted in pow- 
ders of fenugreek, lupin, and wormseed, in dosage increasing up to 45 
gm. daily. This seems rather suggestive of veterinary medicine, but 
both Dinguizli and Robin reported patients benefited. As with so 
many other methods, the digestive disturbances mentioned sufl&ci- 
ently explain any benefit produced by the treatment of Avicenna. 

Trincavella (1476-1568), a Venetian, observed three cases of dia- 
betes. In one, the etiology was attributed to persecution and grief. 
In another, the relatives are said to have demonstrated the truth of the 
Galenic doctrine that diabetic urine is the unchanged drink, by fre- 
quently tasting the urine and finding the taste identical with what the 
patient had been drinking. Cantani suggests that the drink in this 
case was sweet tea. 

Amatus Lusitanus and Zacutus Lusitanus, Portuguese physicians of 
the forepart of the sixteenth century, named dietary, alcoholic, and 
venereal indiscretions among the causes of diabetes. The latter con- 
sidered the seat of the diabetic disturbance to be not only in the 
kidneys but even more in the stomach; he thus holds a transitional 
position in regard to theory between Galen and RoUo. 



HISTORY 7 

Aureolus Philippus Theophrastus Paracelsus Bombast ab Hohen- 
heim (1493-1541) broke radically away from all old dogmas, in this 
as in other subjects. He performed the first chemical experiment, 
and, with surprisingly accurate insight, drew from this crude observa- 
tion the first chemical concept of diabetes. The experiment con- 
sisted in evaporating the urine; it was found that a "measure" of 
urine yielded four ounces of "salt." Paracelsus therefore afl&rmed 
that diabetes is a systemic disease, characterized by the formation of 
an abnormal salt in the blood. The polyuria is not due to a renal lesion, 
but the salt "makes the kidneys thirsty; for thirst always comes from 
salt." He was accustomed to taste the urine of patients, but for some 
reason failed to discover the sweetness of diabetic urine. 

Geronimo Cardano (1505-1576), an Italian, claimed that a girl of 
eighteen years took seven pounds of food and drink daily and excreted 
thirty-six pounds of urine, thus proving Celsus' notion that the fluid 
output is greater than the intake in diabetes, the excess being suppos- 
edly drawn from the air. In addition to this mistake, there is evidence 
that the girl did not even have diabetes; but a step forward is repre- 
sented by this first record of a case history and a chnical experiment. 

Rembert Dodonaeus (1517-1586), a Dutch physician, first mentioned 
chyluria in a diabetic' 

Johann Baptista van Helmont (1578-1644), of Brabant, followed 
the chemical theory of Paracelsus and regarded diabetes as a disease 
of the blood. He was the first to record an observation of diabetic 
Upemia.' 

Franciscus Deleboe Sylvius (1614-1672), professor at Leyden, took 
a step backward, in holding that the offending substance in the blood 
in diabetes is a volatile salt. 

' "Albida autem urina erat, non transi)arens, et paulo quam serum lactis 
tenuior." 

' "Atque in diabete, totus cruor mutatur in lotium lacteum." 



II. The Second or Diagnostic Period (1675-1796). 

Thomas Willis (died 1675), Sidley Professor in Oxford University, 
was the first Englishman to make an important contribution to the 
knowledge of diabetes. This was the simple observation that the 
urine is "wonderfully sweet, as if imbued with honey or sugar."' He 
did not guess that the sweetness is actually due to sugar. He held to 
the theory that diabetes is a disease of the blood. The water is not 
properly combined with the solid matter, so that the water escapes 
through the kidneys, carrying large quantities of salts with it. Per- 
Jiaps there is some disorder of the kidneys also. The resulting thick- 
ening of the blood causes the excessive thirst. Urine containing so 
much salt should taste salty; "but why it is wonderfully sweet like 
sugar or honey, this difficulty is worthy of explanation." He thinks 
it may be explained by the manner in which acids and salts alter one 
another's taste. Acid salts are formed in the blood in various diseases. 
Also a possible source of such acids is fermentation, as of wine and cider. 
Therefore immoderate use of these liquors is a leading cause of dia- 
betes. It may also be brought on by bad hygiene, worry, and nervous 
aiknents. Treatment should aim to thicken the blood and supply 
salts. Accordingly, milk, rice, and starchy and gummy foods are 
indicated; and by Umiting a patient to a diet of milk and barley-water 
boiled with bread, Wilhs became the author of the first carbohydrate 
or undernutrition cure. He employed Hme-water as a beneficial form 
of salt; it held a high place in diabetic therapy for well over a century, 
and was the first alkali to come into general use in diabetes. Certain 
other drugs owed their general adoption largely to his example, even 
though he was not the first to use them. Thus, his antimony treat- 
ment was in favor more than a century after his death and led to some 
interesting developments, and his Dover's powder and tinctura the- 
baica fastened upon the medical profession an opium habit in diabetic 

' "Quasi melle aut saccharo imbutam, mire dulcescere." 

8 



HISTORY 9 

treatment which is very difl&cult to break even at the present time. 
Superficially, the sweet taste of the urine appears such a primitive and 
fortuitous observation as might have fallen to the credit of anybody 
in the 2000 years of European medicine from Hippocrates to Willis. 
But, with due allowance for the inevitable element of chance, the above 
record makes it clear that this, like most discoveries, fell to the lot of 
the man whose point of view and whose methods were capable of yield- 
ing discoveries. It marked a triumph of modern independent thought 
and objective clinical study over subservience to authority and dogma. 
It was of epoch-making importance in the history of diabetes; first, 
because it established a radically new and decidedly more accurate 
basis for diagnosis, which had previously depended upon polyuria and 
other uncertain symptoms; and second, because it led first to the 
dietary treatment of RoUo and his successors and later to the experi- 
mental work of Claude Bernard and all subsequent investigators of the 
normal and abnormal metaboHsm of carbohydrates. It may in some 
measure be due to the stimulus given by Willis that for nearly two 
centuries (viz., until Bernard and Bouchardat transferred the leader- 
ship to France) the important progress in the subject of diabetes was 
practically confined to Great Britain. 

Thomas Sydenham (1624—1689), hailed as a second Hippocrates in 
general medicine, contributed nothing of value in diabetes except a 
clearer definition as a disease of metabolism. Because the nutritive 
elements of the blood are not properly prepared for assimilation, they 
pour out through the kidneys, and the flesh and strength melt away.' 
Later h3^otheses of free versus combined sugar are here anticipated. 
In treatment, Sydenham prescribed narcotics and theriak; also, "Let 
the patient eat food easy of digestion, such as veal, mutton, and the 
like, and abstain from all sorts of fruits and garden stuff;" but no 
effective dietetic treatment grew out of this advice. 

Richard Morton (died 1698) likewise regarded diabetes as "a con- 
tinual flow of nutritive juice pouring out through the kidneys, which 

' "Sued sanguini illati per vias urinarias crudi, et inconcocti, exitum sibi 
quaerunt; tuide sensim labefactantur vires, colliquescit corpus, et quasi substantia 
ejus per banc cloacam exinanitur, cum siti, ardore viscerura, lunxborum coxarum- 
que intumescentia, et salivae spumosae exspuitione crebra." 



10 CHAPTER I 

frequently befalls intellectual persons, and drinkers of brandy and 
diuretic liquors."" He was the first to note its hereditary character. 
Milk, diet was a feature of his treatment. He opposed the bleeding 
and purging in use among some physicians. 

Richard Mead (died 1754) was the first to consider diabetes a dis- 
ease of the liver, and brought supposed necropsy evidence in support 
of this view. On the Continent also began a careful postmortem 
search for lesions causing diabetes, but nothing of significance was 
found. 

Matthew Dobson (1775) completed the discovery of Willis, and 
with his paper in English, the history of diabetes emerges froni Latin 
into the modern languages. He first grasped the fact that the sweet 
substance in diabetic urine is sugar, proving this experimentally by show- 
ing that such urine was subject to alcoholic and acetic fermentation, 
did not coagulate on heating or addition of a mineral acid, but on 
evaporation four pounds of a patient's jirine yielded a whitish cake 
weighing four ounces, two drams, and two scruples. This cake 
"smelt sweet, like brown sugar, and could not be distinguished from 
sugar, except that the sweetness left a slight sense of coolness on the 
palate." The urine of the same patient in convalescence yielded a 
less abundant dark residue which was not sweet. Dobson also was the 
first to discover a sweet taste in diabetic blood serum. He therefore 
concluded that the sugar contained in normal chyle is assimilated by 
the body, so that the trace in normal blood is so slight that its taste is 
overcome by that of the salts. In diabetes this transformation is 
slowed, so that sugar accumulates in the blood. Also, the quantity 
of sugar in some cases is too great to be derived entirely from the chyle, 
therefore sugar must be formed by some abnormal fermentation in the 
body. The diabetic loses flesh and strength because of the loss of 
nutritive material in the urine, therefore he should eat as much as 
possible to make up for this loss." 

^^ "Continuus succi nutritii fliixus per renes decurrens, qui cogitandibus, et 
vini Gallici liquorumque diureticorum potatoribus plerumque accidit." 

" A prototype of the modern fallacy of replacing through the diet the calories 
lost in the urine. 



HISTORY 11 

Thomas Cawley*^ (1788) by a careful account of a single case, earned 
credit for the first example of diabetes decipiens, the first diagnosis 
of diabetes by demonstration of sugar alone, and the first description 
of a pancreatic lesion in a diabetic necropsy. He, however, regarded 
diabetes as a disease of the kidneys. 

William Cullen (1709-1790) was the first to regard diabetes as a 
disease of the nervous system, comparing the polyuria with that seen 
in spastic states. He also wrote: "I think I have met with one in- 
stance of diabetes, in which the urine was perfectly insipid; and it 
would Seem that a like observation had occurred to Dr. Martin Lister. 
I am persuaded, however, that such instances are very rare, and that 
the other is by much the more common and perhaps the almost uni- 
versal occurrence, I judge, therefore, that the presence of such a 
saccharine matter may be considered as the principal circumstance in 
idiopathic diabetes." Thus, Cullen and Lister called the attention 

'^ This name often appears in the literature incorrectly as Cowley. The essen- 
tials of his concise report are interesting to quote verbatim. 

"Allen Holford, Esq., aged thirty-four years, strong, healthy, and corpulent, ac- 
customed to free living and strong corporeal exertions in the pursuit of country 
amusements, in December, 1787, was seized with diabetes; but the cause of the 
great degree of emaciation and debiUty which gradually came on was not dis- 
covered until March 20, 1788; at which time his urine was found to be sweet, 
fermentable with yeast, and two pounds, on evaporation, jdelded about five or six 
ounces of sweet black extract, exactly resembling that preparation of melasses 
made by confectioners for children, and vulgarly called coverlid. 

"Within the above mentioned period the quantity of urine evacuated was never 
observed to exceed what is usual in health, or to be disproportioned to the ingesta, 
though the state of it had been frequently inquired into, and even the quantity of 
liquids drank and voided measured. For these reasons the quality of it was not 
suspected until it became inconceivable, considering the quantity of aliment taken 
in, how such a degree of exhaustion could ensue, unless the body was drained by 
the quality of what was rejected as apparently excrementitious. 

"Variety of medicine, the usual consequence of inefficacy and despair, were suc- 
cessively administered. Decoction of bark with vitriolic acid and alum, with 
astringents and aromatics, with chalybeates, with sacc. saturni and opium, and with 
cantharides, together with cold bathing in salt water, were theprincipalmeans used, 
and at first had a very good effect; but soon afterwards every medicine disagreed 
with the stomach, and the patient gradually sunk and died on the 18th of June." 

"The pancreas was full of calculi, which were firmly impacted in its substance. 
They were of various sizes, not exceeding that of a pica, white, and made up of a 



12 CHAPTER I 

of the medical profession to the possible existence of diabetes insipi- 
dus.i' GuUen first added the adjective "mellitus" to the name of the 
disease. Cullen's theory of diabetes was that of Dobson, with whom 
he had discussed it. "I formerly communicated this idea to Dr. 
Dobson, who adopted it, and published it; but I must confess that 
the theory is beset with difficulties, which cannot at present be solved." 
He gave a wholly pessimistic view of the treatment and prognosis; 
he had tried the known methods on twenty diabetic patients and failed 
to save any of them. 

John Brown (1735-1788) conceived life as motion. Diabetes, as a 
disease of weakness, should be treated by exercise, which should be 
neither too slight nor too severe. But Brown's treatment was inferior 
to that of his predecessor Celsus, in that abundance of food and drink 
was also prescribed for strengthening. 

Johann Peter Frank (1745-1821), the most renowned German phy- 
sician of his time, gave the name of diabetes decipiens, or deceptive 
diabetes, to the condition of glycosuria without polyuria described by 

number of lesser ones, which made their surface rough, like mulberry stones; and 
in all respects they appeared analogous to the calculi which we sometimes meet 
with in the salivary ducts. The right extremity of the pancreas was very hard, 
and appeared to be scirrhous." 

"Experiment I. — A small quantity of urine, set by in a phial, spontaneously 
entered into the viaous, and then into the acetous fermentation, discharging a 
great quantity of mephitic gas. A white cloud formed in the center, which gradu- 
ally fell to the bottom in the form of a white precipitate. In short, the whole of 
this experiment corresponded with Dr. Dobson's." 

"Experiment IV. — ^A small quantity of the extract put into spirit of wine neither 
dissolved nor communicated any colour to it, but immediately became very hard 
and brittle. 

"It appears, by the last experiments, that the extract consists of sugar united 
with gummous or coagulable matter, all of which ought to remain in the body for 
its support, and that little of what is excrementitious passed through the kidneys 
but superabimdant water, the vehicle of this nutritious matter." 

^^ They did not clearly demonstrate the existence of such an entity, for Bard- 
sley (mentioned by Watt, p. 14, who gives the above quotation) criticized their 
findings by showing that a urine with no perceptible sweet taste might form 
more or less oxalic acid when examined chemically. This formation of oxalic acid 
on treatment with a mineral acid was the first chemical method for the demon- 
stration of sugar in urine, and was used by RoUo and his immediate successors. 



HISTORY 13 

Cawley. He also established the definite division and nomenclature 
of diabetes insipidus or spurius and diabetes mellitus or verus. 

Francis Home diflCerentiated "watery" and "milky" diabetes." He 
proved experimentally that the urine of a diabetic patient was not in 
excess of the fluid in food and drink. He isolated sugar from the urine 
of two patients, respectively an ounce and an ounce and a half of 
sugar to the pound of urine. Addition of yeast to the urine was fol- 
lowed by fermentation; the urine lost its sweetness and acquired the 
taste of small beer. He failed to confirm Dobson's observation of the 
sweetness of diabetic serum. He upheld Dobson and CuUen's theory 
of diabetes as a defective assimilation of food. The sweet urine, 
milky in some cases, was evidence to him that vegetable foods are not 
properly assimilated in diabetes; the sweet chyle, which is the first 
product of digestion, is not converted into ammonium salts as it nor- 
mally should be. Therefore diabetes should be curable by strict meat 
diet; but he was unable to make this theory succeed in practice, and 
he went on to try a multitude of drugs without result. Given suffici- 
ent courage or skill to build on this theory a successful practical 
method, he might have been the founder of the new era of therapy. 

^*The relatively frequent mention of milky urine among early writers is re- 
markable. Perhaps the appearance was due to fermentation. Whether in the 
absence of dietary regulation there may have been occasionally a true visible 
lipuria is a possible question of interest. 



III. The Third Period, or Period of Empiric Treatment 
(1796-1840-50). 

John Rollo, a surgeon-general of artillery in the English army, 
ventured to try an entirely original method on the first case of dia- 
betes that he had ever treated. "For the case I had seen at Edinburgh, 
and Dobson's account, with Dr. CuUen's opinion, had prepossessed 
me with the idea of the disease being a primary and pecuUar affection 
of the stomach" ( (2), p. 5)." This first patient, a certain Captain 
Meredith, treated in 1796, shares some of his physician's fame, not 
unjustly, in view of what he went through. The treatment began 
with bleeding, which is said to have made the patient feel better. 
Confinement to the house was ordered, preferably to one room, with 
the utmost possible quiet and avoidance of exercise. The bill of fare 
was as follows: "Breakfast, I5 pints of milk and J pint of lime-water, 
mixed together; and bread and butter. For noon, plain blood pud- 
dings, made of blood and suet only. Dinner, game, or old meats, 
which have been long kept; and as far as the stomach may bear, fat 
and rancid old meats, as pork. To eat in moderation. Supper, the 
same as breakfast." The skin was to be greased daily with hog's 
lard, flannel worn next the skin, and an ulceration about the size of 
half a crown to be maintained opposite each kidney. At first, kali 
sulphuratum was ordered several times daily, but later this was ex- 
changed for "hepatised ammonia" (ammonium sulphide), "a medicine 
proposed by Mr. Cruikshank, who was of the opinion that it might 
prove a more certain and active medicine than the other on the stom- 
ach, in diminishing its action, as well as that of the system in general." 
Wine of antimony and tincture of opium were to be taken at bedtime, 
and "in reserve, as substances diminishing action, tobacco and fox- 
glove." Captain Meredith's age was thirty-four, and his diabetes of 
seven months' standing, apparently moderate in degree. He steadily 

^' This rules out the statement by various authors that Rollo received his stimu- 
lus from Home. 

14 



HISTORY 15 

improved, in spite of occasional indulgence in apple pie or beer. Along 
with the gain in strength and disappearance of symptoms, Rollo noted 
diminution in the quantity and sweetness of the urine, in the amount 
of sugar obtained on evaporation, and in the oxalic acid test. After 
cessation of glycosuria, the strict diet was gradually relaxed, and it is 
complimentary to RoUo's judgment that the first vegetables permitted 
were cabbage, boiled onions, salad, mustard, common radish, and 
horse-radish. The patient resumed his military duties. Rollo under- 
took his second case, that of "a General Officer." Here the diabetes 
was of three years' duration, and the patient, aged fifty-seven, re- 
peatedly broke even the rather mild regimen imposed, so that he 
ultimately died. 

Various other matters of interest are contained in Rollo's book. 
The diuretic action of sugar is clearly recognized. ((2), p. 24) : "The 
serum of the blood apparently containing less saccharine matter than 
the urine, may depend on the power of the kidneys in separating it 
in common with the other saline matters of the blood; but proving a 
new and peculiar stimulus, their action is increased, and the saccharine 
matter consequently separated speedily and in proportion to its for- 
mation in the stomach." (P. 37) : "A diet of animal food, as rancid as 
possible, was proposed in our case, with the view of preventing the 
formation of sugar in the stomach, and by that means to remove the 
peculiar stimulus which supported the increased action of the kid- 
neys." A number of other physicians wrote enthusiastically concern- 
ing the benefits of the new method. Currie (pp. 147 and 184 of 
Rollo's book, 1798) reported experiments of weighing ingesta and 
egesta, weighing the patient before and after bathing, etc., to refute 
the ancient error of excess of fluid output over intake. Marshall de- 
scribed a necropsy showing lipemia, "chyle in the subclavian vein;" 
and "there appeared to be no proper blood in the body, but instead of 
it, a hquid nearly resembling well made thin chocolate. All the veins 
were filled with this singular brown blood, which had a sickly, sweet- 
ish, slightly sour smell (not tasted)." On page 331 is the first re- 
corded observation of an important phenomenon, — a diabetic aged 
twenty-five, "with the odor of decaying apples in his breath." The 
letters from physicians show that diabetes was a rarity and a curiosity 
to them. Dr. Monro is quoted (p. 364) in a statement of the nature of 



16 CHAPTER I 

diabetes, which may well bear comparison with present-day views: 
"Were I to give a theory of this wonderful disease, I would say that it 
arises from a defect of the animal or assimilatory process, by which the 
aliment is converted into the nature of our body." RoUo's theory was 
inferior to that of Dobson and Monro. He held that diabetes is a 
disease of the stomach, with increase of its activity, secretion of an 
abnormal gastric juice, and probably increased activity of the lac- 
teals; that "the saccharine matter is formed in the stomach, and 
chiefly from vegetable matter." The source of sugar was to be cut 
oif by restricting the diet to animal food; but milk was provisionally 
included under animal food, and, to indulge the patient, a little bread 
was permitted. Also, the abnormal activity of the stomach should be 
depressed, so as to check bulimia and restore the secretion of a normal 
gastric juice. Therefore, drugs were chosen to produce anorexia and 
nausea — ammonium sulphide, antimony, opium, digitalis, tobacco. 
The use of rancid fats in the diet was for a similar purpose. Fat in- 
deed was responsible for the first fasting treatment of diabetes (RoUo 
(2), p. 36). "Thus Villanovanus relates that a certain man, affected 
with this disease, eat pot-bread dipt in lees of oil; and that a woman in 
the like case drank twice the melted fat of beef, with a like quantity 
of hot oil; and that both these patients contracted so great a loathing 
of food, that neither of them eat anything for five days, and so got rid 
of their distempers." It so happened, therefore, that the very incor- 
rectness of RoUo's theory aided in his therapeutic success. From the 
results achieved with his method by himself and others, he drew the 
conclusion (p. 141) that "diabetes mellitus is so far understood as to be 
successfully cured." 

Dupuytren and Th6nard reported good results from the RoUo diet 
in France, considering it as specific for diabetes as quinine for malaria; 
yet they recognized that the cure is never complete, as patients re- 
lapse whenever they discontinue the diet. They investigated the 
properties of diabetic urine, demonstrating that on fermentation it 
yielded carbon dioxide and alcohol; this was considered to prove the 
presence of sugar, but this sugar was thought to be of a peculiar kind 
with little taste. 

Nicolas and Gueudeville held a theory similar to that of RoUo. 
They regarded diabetes as a disorder of intestinal digestion; the chyle 



HISTORY 17 

is normally composed of nitrogenous substances, but in diabetes it 
contains imperfectly elaborated materials saccharine in character and 
unsuited for the nutrition of the body. 

Robert Watt (1808), a Scotchman, reported benefit from treating 
diabetes with the Rollo diet, bleeding, bhstering, antimony powders, 
and sometimes mercury. Both food and drink were severely restricted 
in quantity. Watt's clinical ability, and the position properly belong- 
ing to him in the history of this subject, may be indicated by quota- 
tions from his remarkable little book." His admonitions may be 
profitable to many even at the present time. 

Thomas Christie (1811) first brought to European notice the fact 
that diabetes was known to the ancient Hindus. He described the 
frequency of diabetes in Ceylon, and his success with the Rollo treat- 
ment there. 

"Watt, preface: "The rapid restoration of health after venesection, blistering 
and an abstemious diet in cases, where from the great prostration of strength and 
excessive emaciation, a stimulating mode of treatment seemed indicated, dis- 
closes views of the animal economy by no means favourable to some modern opin- 
ions. It is to be feared that a dread of debility and an emaciated state of body, 
from an inflammatory, not a hectic cause, have sometimes deterred practitioners 
from employing depletion, and the patient has been quietly resigned to his fate. 
As diabetes is so obviously aggravated by too much aliment or stimuU, and as 
there is such an attendant buUmia, the first aim of the practitioner should be 
to remove a portion of that food, which, since it does not nourish, must oppress 
and injure the system. Animal diet accomplishes this object to a certain ex- 
tent, for during its use, the quantity of ingesta is necessarily diminished, and a 
partial abstinence is enforced. More might have been done if, instead of an 
exclusive confinement to animal food, the quantity of ingesta were gradually 
diminished, till no more were received than the digestive organs could easily 
prepare, and the functions of assimilation successfully convert to the support 
and nourishment of the system. Artificial depletion may, in some measure, 
supersede the necessity of too strict adherence to an abstemious diet; but the end 
will imdoubtedly be more easily, and effectually accomplished if the patient can 
exert the requisite fortitude to resist the cravings of appetite, and to repress urgent 
thirst. These indulgences increase the flame, which sooner or later consumes the 
patient. We aid the cure by a diminution of the supply, and the same means pro- 
tract the fatal period, or smooth the passage to the grave, when a cure is beyond 
the reach of art." 

Watt (p. 29 ff.) described the treatment of a laborer suffering from moderate 
diabetes. The man was bled daily, the quantity of blood taken being generaUy 



18 CHAPTER I 

Chevreul in 1815 demonstrated that the sugar of diabetic urine is 
identical with glucose. 

Latham (1811) distinguished two forms of diabetes, the saccharine 
and the seirous. Likewise Gregory (1825) described the differences 
between diabetes mellitus and diabetes insipidus. Such observa- 
tions were of importance in settling the existing doubts among the 
medical profession as to the decisive import of glycosuria for the diag- 
nosis of diabetes. 

Pelham Warren (1813) may be mentioned as the leading English 
opponent of the Rollo treatment. He regarded dietary restriction as 
of merely secondary importance, and voiced the frequent objection 
that patients would not adhere to such a diet. He placed chief de- 
pendence on large doses of opium, by which, without dietary regula- 
tion, he obtained diminution of glycosuria and polyuria. Some 
authors have referred to him as the originator of opium therapy. He 

fourteen or eighteen ounces, but on one day twenty-four ounces. The bleedings 
were well borne, and after^ twelve days there was marked improvement. Anti- 
mony powders were also used, and the patient in consequence "was very sick and 
uneasy all day; had no appetite for food." Again (p. 35): "The antimonial 
powders appeared to have a more decided effect. They produced very severe 
sickness, vomiting, and commotion in the stomach and bowels. The night after 
taking these, the urine was greatly reduced, and next day he found himseK un- 
commonly weU. On repeating them, they had not such violent effects, nor was 
the relief obtained so decisive. . . . Anything which produces sickness has 
a temporaiy effect in relieving diabetes, by diminishing the quantity of ingesta. 
The antimonial powders seemed to possess no other specific action. During the 
two days he was under their influence, he vomited everything, and was not dis- 
posed to take either meat or drink, hence when the supply is cut off, the excretion 
must diminish of course." (P. 204) : "The loss of balance between the digestive 
and assimilative organs may be produced in two ways" (underf unction of lungs or 
overfunction of lacteals). (P. 205) : "In some diseases the receptive power is not 
only continued but even increased, whUe the assimilative powers remain at or 
below their normal level." Finally, (p. 212): "Diet. From the very nature of the 
disease, abstinence becomes an indispensable part of the practice. This doctrine, 
however, is often very contrary to the feelings of the patients, who are apt to urge 
in their defence that nature is the best judge of what is necessary for their support. 
They feel weak, they have a strong craving for food, and they can see no reason 
why they should be deprived of what makes other people strong. These argu- 
ments are frequently repeated, though every meal might convince them that it 
has added to their burden and not to their strength." 



HISTORY 19 

failed to take account of the effect of opium upon appetite, and he may 
be considered the founder of the erroneous belief, still widely prevalent, 
that opium has an actual specific effect upon diabetes. 

RoUo's treatment seems to have met with chiefly an adverse judg- 
ment in Germany." It never gained general adoption by the medi- 
cal profession of any country, unless perhaps England; and though 
it always had eminent supporters, and more or less restriction of carbo- 
hydrate continued to prevail, yet the weight of opinion and practice 
even in England gradually turned against strict animal diet. The 
decline in popularity may be attributed to the crudeness and imper- 
fections in the method itself, the careless and faulty application of it 
by most physicians, the rebellion of patients — ^who generally, sooner 
or later, secretly or openly broke the intolerable dietary restrictions 
and relapsed — the failure of the method to check the severest cases, 
and the frequent bad results, well understood nowadays, of changing 
diabetic patients suddenly from mixed diet to strict protein-fat 
regimen. 

Prout, though transitional in time and influenced in his later years 
by Bouchardat, may be mentioned as closing this period. Naunyn 
( (5), p. 388) credits him with being, in the 1820 edition of his book, 
the first to restrict protein in diabetes; but such instructions (1848 
edition, p. 40) were intended only to forbid overloading the stomach 
at any one time, so that Front's advice was not superior to RoUo's and 
far inferior to Watt's. His treatment was based on the theory (p. 38) 
"that diabetes is nothing more nor less than a form of dyspepsia; 
that this dyspepsia principally consists in a difficulty of assimilating 
the saccharine alimentary principle." He did not approve of strict 
animal diet, but gave especially green vegetables with it. He (p. 44) 
introduced the use of bran bread, to be made with eggs and milk, the 
bran being finely ground to avoid irritation of a sensitive intestine,^' 
and washed in a cloth till the water came through clear to remove 

^' Cf. unfavorable experiences reported by von Stosch, Wolff, and Horn, ref. by 
Ebstein((2), p. 11). 

'* Camplin (1858) stated that the use of bran for diabetic bread had been known 
for a long time, but it was not highly considered. He was a diabetic treated by 
Prout, and suffered diarrhea from bran bread; therefore he originated the plan of 
having the bran ground very fine in a special mill. 



20 CHAPTER I 

starch. He limited drink as well as food. He employed bleeding, 
Dover's powder, antimonials, and other drugs, but cathartics only as 
needed to regulate the bowels. In thirty years of practice he saw 700 
diab.etics. He considered that cold, dampness, or malaria brings on the 
disease in predisposed persons. He described the frequency of phthisis 
as a fatal complication, the liability to sudden death from indigestion, 
travel, or exhaustion; and in particular, he was the first to mention 
coma as the typical termination of diabetes, as follows: (pp. 28-29) 
"The person and breath of the patient often exhale a sweetish hay- 
like odour. Accompan3dng these bodily symptoms there is great de- 
pression of spirits and despondency. .... The breath becomes 

short, and there is more or less of cough and expectoration 

The emaciation and debility now rapidly approach the maximum; the 
tongue and fauces assume a dark red colour, and often become aph- 
thous; the urine generally diminishes in quantity, and loses much of 
its saccharine property; the feet and legs become edematous; and, 
finally, after almost a total suppression of the renal secretion, the 
patient becomes comatose, in which state he expires." Also (p. 61.) : 
"In young children, the sudden withdrawal "of fluids, as well as the use 
of opium, require caution, from the tendency of these expedients to 
cause a suppression of urine, which is almost certain to terminate in 
coma and death." 



IV. Modern or Experimental Period. 

Though this period began in the decade 1840 to 1850, the way was 
prepared, as usual, by a few brilliant forerunners, who may properly 
be included here. 

Lavoisier" (1743-1794), who discovered the most important 
properties of oxygen, substituted chemical union for the phlogiston 
hypothesis, and determined that plants consist essentially of carbon, 
hydrogen, and oxygen, while animals contain also nitrogen, pointed out 
the relation of oxygen to the processes of life. He proved that it, 
and not nitrogen, is essential for respiration. He recognized that 
animal life and heat are dependent on oxidation. He performed the 
first experiments concerning human respiratory metabolism, and 
actually obtained correct values for the normal oxygen consumption 
of man, and demonstrated the increase due to cold, work, and diges- 
tion. Such an achievement is a most remarkable display of genius in 
a man whose work preceded RoUo's publication, and whose career was 
untimely ended by the guillotine of the French Revolution. Further 
research was lacking in this line until Regnault and Reiset in 1849 
conducted experiments with a respiration chamber for animals. 

Tiedemanh and Gmelin (1827) in animal experiments proved that 
sugar is normally formed from starch in digestion. By the fermenta- 
tion test they also demonstrated sugar in the portal and systemic 
blood of animals after carbohydrate feeding, but supposed it to be 
absorbed through the chyle. . 

Ambrosiani, also Maitland,^" by the same method discovered the 
presence of fermentable sugar in the blood of diabetic patients, though 
Claude Bernard criticized their results because white of egg was used 
to clarify the solution. M'Gregor claimed to find sugar in the vomitus 
of a diabetic who for three days had received only roast beef and water, 
thus, supposedly demonstrating the origin of diabetes in an abnormal 

'^ See Lusk, Chapter I. 
^^ Mentioned by M'Gregor. 

21 



22 CHAPTER I 

gastric function. He also reported the presence of sugar in diabetic 
saliva and feces. Also, by fermentation, he demonstrated sugar in the 
blood of a considerable number of his diabetic patients, and found 
traces in the blood of normal persons during digestion of starch. Mag- 
endie and von Frerichs confirmed these blood sugar findings.''^ Mean- 
while Thomson had attempted the first quantitative determination, 
fijiding by fermentation only 0.03 to 0.06 per cent of sugar in chicken 
blood. 

Other movements in science about this time must be borne in mind 
in connection with the remarkable new developments in the field of 
diabetes: Wohler's synthesis of urea in 1828, breaking down the sup- 
posedly absolute barrier between the domains of the organic and inor- 
ganic; the cell theory enunciated by Schleiden in 1838 for plants, and 
by Schwann in 1839 for animals; the beginning of Virchow's work on 
cellular pathology with his appointment as Privatdozent at Berlin in 
1847; and meanwhile the laying of the foundations of physiological 
chemistry by Liebig. In addition to the deeper problems thus thrown 
open, certain chemical tests deserve notice; these were the polari- 
metric determination of sugar discovered by Biot in 1833, the first 
copper reduction qualitative test devised by Trommer and announced 
after his death by MitscherUch in 1841, and the quantitative method 
of Fehling in 1850. It is hard to overestimate the important influence 
of these easy and striking sugar tests upon the development of the 
theory of diabetes. Also, by furnishing the first means for the accurate 
qualitative and quantitative detection of sugar even in small quanti- 
ties, they had a great and immediate effect on both diagnosis and 
treatment. 

Claude Bernard contributed nothing directly to the treatment of 
diabetes, but stands as an epoch-making figure of the new period be- 
cause of the extensive physiological researches by which he not only 
founded modem knowledge of carbohydrate metabolism, butjalso 
clearly established animal experimentation as a method for solution of 
the problems involved. His scientific career began in 1847, his first 
work being the demonstration of sugar in the right-heart blood of dogs 
fed exclusively on meat. This inconclusive experiment seemed then 

*^ For other early literature see von Mering ( (1), p. 386). 



HISTORY 23 

to overthrow the prevailing doctrine that only plants and not animals 
can form sugar from non-carbohydrate materials. By this and other 
experiments Bernard founded the theory of sugar formation from pro- 
tein, which was not to receive actual proof until some years later. 
He performed the first reasonably accurate quantitative determina- 
tions of blood sugar, some of his values being too high, presumably 
because of injury and excitement of the animals, but other figures, 
such as 0.107 per cent, being of a character now recognized as normal. 
He discovered glycogen and the glycogenic function of the liver; he 
considered that glycogen is formed from either the carbohydrate or 
the protein of the food, and that the liver from its glycogen suppHes 
sugar to the circulation in the intervals between digestion. He ob- 
served sugar formation from glycogen in the liver post mortem, and 
proved that the process was due to a diastatic enzyme, which was held 
to be the agent of this action also during life. He discovered curare 
glycosuria, and, more important, the glycosuria produced by puncture 
of the floor of the fourth ventricle, giving the first experimental foun- 
dation for the conception of nervous glycosuria. To Bernard, dia- 
betes and piqiire glycosuria were temporary and permanent forms of 
the same thing. The nervous irritation was supposed to cause 
splanchnic vasodilatation and hyperemia of the liver; this produces 
increased contact between liver glycogen and blood diastase, and the 
resulting acceleration of glycogenolysis floods the body with sugar, 
the excess of which flows away in the urine. It was thus a pure over- 
production hypothesis, and the liver was in Bernard's opinion the 
organ principally concerned. 

Mialhe in 1845 announced the discovery of the diastase of saliva. 
Apparently as an outgrowth of his diastase studies, he set up the hy- 
pothesis that diabetes is a primary acidosis, that the blood of patients 
has an acid reaction due to ingestion of too much acid, or to deficient 
sweating and the resulting retention of acids; and he introduced a 
treatment with large doses of alkali, especially sodium bicarbonate and 
magnesium hydrate. Though claiming some benefits at first, he and 
those repeating his attempt soon met failure. Under the tests of 
Bouchardat, Griesinger, Kulz, and others, both theory and therapy 
fell. Later Mialhe (3) concluded that the primary cause of diabetes 
does not consist entirely in an abnormal composition of the blood, but 



24 CHAPTER I 

in an essential nervous disorder. The fallacious comparison between 
the diabetic process and the r61e of acids in the hydrolysis of starch or 
glycogen in vitro has caused such a theory to reappear in various forms 
from that time to the present. 

Though Bouchardat (1806-1886) read his first memoir to the Acad- 
emy of Sciences in 1838, and the final edition of his book appeared in 
1875, he came into prominence thrbugh important contributions in the 
decade 1840 to 1850. Like Rollo and aU other founders of the dietetic 
treatment, he considered diabetes a disease of digestion. According to 
his theory, normal gastric juice has no action upon starch, which is di- 
gested in the intestine; but in diabetes, an abnormal ferment digests 
starch in the stomach, and glycosuria, polyuria, and other symptoms 
result. He claimed to demonstrate the presence of diastase in the 
vomitus of diabetics and its absence in that of normal persons."^ 
Hypertrophy of the stomach and atrophy of the pancreas in diabetic 
necropsies were also held to support his theory; and he was thus 
the first to suggest an influence of the pancreas in the causation 
of diabetes, and the originator of the attempt to produce it by pan- 
createctomy in dogs.^* For sugar determination in urine, he used 
fermentation, the polariscope, and the Frommherz copper reagent. 
By the fermentation method he showed the presence of sugar in dia- 
betic blood, but found none in normal blood. At how low an ebb 
was the Rollo treatment at this time is shown by the pleading and 

'^^ Various other authors reported similar results: cf. Griesinger, pp. 41-42. 

^' Some authors attribute the first pancreatectomy to Brmmer in 1686, but his 
extirpation aimed only to produce hypertrophy of the duodenal glands named after 
him, and involved less than half of the pancreas. Bouchardat ((2), p. 108) 
ascribed to Haller (1708-1777) the observation that depancreatized dogs show 
polydipsia, polyphagia, emaciation, and death. This statement has been widely 
copied in the literature. But pancreatectomy to the point of diabetes was scarcely 
possible at such an early datCj and as Haller apparently never published any such 
work (cf. Sauerbeck), the entire myth seems to have originated in a mistake of 
Bouchardat. The first attempt at total extirpation and the first idea of producing 
diabetes by this means were represented in Bouchardat's publication in 1846 of 
experiments undertaken with Sandras to support the pancreatic origin of diabetes. 
The dogs did not survive pancreatectomy, and ligation of the pancreatic duct did 
not produce diabetes. The undeveloped state of surgery therefore barred Bou- 
chardat from reaping the fruits of his brilliant intellectual perception in this field. 



HISTORY 25 

arguments of Bouchardat ( (1), p. 10). He begs all friends of truth 
to hear him; whatever be the original cause of glycosuria, diabetics, 
who otherwise all die, are actually saved when his dietetic treat- 
ment is used. Bouchardat in the clinical field ranks with Claude 
Bernard in the experimental field. He is easily the most brilliant 
clinician in the history of diabetes. He resurrected and transformed 
the Rollo treatment, and almost all the modern details in diabetic 
therapy date back to Bouchardat. He was first to insist on the need 
of individualizing the treatment for each patient ( (2), p. 150). He 
disapproved the rancid character of the fats in the Rollo diet, but 
followed an intelligent principle of substituting fat and alcohol for 
carbohydrate in the diet. H.e forbade milk because of its carbo- 
hydrate content. He urged that patients eat as little as possible, 
and masticate carefully; also (1841) he inaugurated the use of oc- 
casional fast-days to control glycosuria. Subsequently he noted the 
disappearance of glycosuria in some of his patients during the pri- 
vations of the siege of Paris. Though the introduction of green 
vegetables is credited by Prout (p. 45) to Dr. B. H. Babington, the 
honor of thus successfully breaking the monotony of the Rollo diet 
.properly belongs to Bouchardat.- He recommended them as furnish- 
ing little sugar, a little protein and fat, but especially potassium, or- 
ganic acids, and various salts. He also devised the practice of boiling 
vegetables and throwing away the water, to reduce the quantity of 
starch when necessary. As a similar trick ( (2), p. 217) he "torrefied" 
(i.e., charred and caramelized) bread to improve its assimilation; 
possibly this is the origin of the widespread medical superstition that 
diabetics may have toast when other bread must be forbidden. He 
invented gluten bread; this started the idea of bread substitutes, 
from which sprang the bran bread of Prout and Camplin, Pavy's 
almond bread, Seegen's aleuronat bread, and the numerous later 
products. Bouchardat also first introduced the intelligent use of exer- 
cise in the treatment of diabetes, and reported the first clinical ex- 
periments proving its value. He showed that carbohydrate tolerance 
is raised by outdoor exercise; and to a patient requesting bread, he 
replied ( (2), p. 228) : "You shall earn your bread by the sweat of your 
brow." There is a modern sound to his complaints ( (1), p. 47) of the 
difficulties of having treatment efficiently carried out in hospitals, of 



26 CHAPTER I 

the lack of adequate variety of suitable foods, of deception by patients, 
and of how, even when improved in hospital, they break diet and 
relapse after returning home. He advocated ( (2), p. 330) daily test- 
ing of the urine, to keep track of the tolerance and to guard against a 
return of sugar without the patient's knowledge. He followed Mialhe 
in giving alkalies, viz. sodium bicarbonate up to 12 to IS gm. per day, 
also chalk, magnesia, citrates, tartrates, soaps, etc., also ammonium 
and potassium salts; he found them often beneficial to the patients 
but not curative of the glycosuria. He told a patient ( (2), p. 120): 
"You have no organic disease; there is merely a functional weakness 
of certain parts of your apparatus of nutrition. Restore physiological 
harmony and you will attain perfect health . " He used glycerol for 
sweetening purposes, and introduced both levulose and inulin as forms 
of carbohydrate assimilable by diabetics, for reasons which well illus- 
trate his intellectual keenness. On giving cane sugar to diabetics, 
he had found only glucose excreted. Was the levulose utilized or 
changed into glucose? Levulose proved under certain conditions to be 
more easily destroyed in vitro than glucose. Accordingly he gave 
levulose and inulin to diabetics, and found no sugar in the urine. 
Therefore he recommended levulose for sweetening purposes, and 
inulin-rich vegetables for the diabetic diet. 

Sir Henry Marsh (Dublin, 1854) criticized the RoUodietas impossible 
to follow because of the indigestion and repugnance to food resulting, 
but he followed the Bouchardat plan with vegetables, and also used 
exercise, warm clothing, and baths, restriction of fluid intake, Dover's 
and James' powders, and alkahes (lime-water and hartshorn, recom- 
mended by CoUes). He condemned bleeding, and found opium tem- 
porary in effect. He noted that an attack of vomiting frequently 
leads to death; also, "I have seen three cases of diabetes terminate 
in fatal coma." 

Fetters (1857), in the clinic of von Jaksch, investigating the peculiar 
smeU noted by various authors, obtained from the urine of a coma 
patient a small quantity of a liquid giving the reactions of acetone. 
An extract of the limgs also jdelded acetone. He therefore attributed 
the cause of coma to poisoning by acetone produced by digestive dis- 
order. Kaulich distilled 700 pounds of diabetic urine, and purified 
enough acetone to identify it by elementary analysis. 



HISTORY 27 

Trousseau condemned the Rollo diet. "I cannot too emphatically 
raise my voice against the abuse of giving an exclusively animal diet 
in diabetes." Intolerable loathing and impairment of health were 
alleged against it. Trousseau followed Bouchardat's method, and 
especially advocated exercise; but he also allowed fruits and even a 
small quantity of bread, and confessed that patients in the emaciated 
stage were beyond hope. He was the first to mention bronzed 
diabetes.''* 

Piorry of Paris, "a man who loved to turn everything upside down,"^' 
brought into some prominence in 1857 a notion which was more ex- 
cusable when first suggested by Chevallier in 1829. Since sugar is lost 
in diabetes and is indispensable to life, it was proposed to replace the 
loss by feeding sugar. Piorry gave only a very incomplete description 
of one case, apparently mild, which he treated by almost complete 
withdrawal of fluids, and by giving daily 125 gm. of sugar candy "and 
two portions of meat." The polyuria necessarily ceased, and the 
sugar excretion remained high in percentage but diminished in total 
quantity. If the author's statement represents the entire diet, his 
treatment was a crude carbohydrate and undernutrition cure. It had 
disastrous consequences. Owen Rees and others are said to have 
taken it up. Schiff — a, physiologist of some repute, an opponent of 
Bernard on certain details of the glycogenic hypothesis, and a careful 
investigator of nervous glycosuria, and one of those who removed the 
pancreas (in birds) without discovering diabetes — also followed it, and 
upon becoming diabetic, he applied this treatment to himself. Al- 
though the diabetes had appeared late in life, it ran a quickly fatal 
course, apparently because of the treatment.^* Naunyn ( (5), p. 383) 
gives another example of injury from this treatment, as applied by a 
quack. Though such a method now seems foolish, it should be noted 

^* (P. SOI) : "I was struck by the almost bronzed appearance of his counte- 
nance, and the blackish color of his penis." Autopsy showed a cirrhotic liver 
twice the normal size. 

^* Griesinger, p. 67. The quack practice of compelling patients to drink their 
own urine is mentioned as something similar. 

^'Naunyn ( (5), p. 388). It is interesting that Schiff (p. 128) had described a 
slight alimentary glycosuria in himself and his brother, without suspecting its 
warning significance. 



28 CHAPTER I 

that the orthodox treatment of severe cases has represented a similar 
attempt to fill a sieve — the calories lost in the urkie being replaced by 
fat in the diet, which merely brings the fatal end more slowly and in a 
different form than does sugar. 

Griesinger in 1859 published an analysis of 225 cases of diabetes; 
and though only eight were his own and the others all from the litera- 
ture, his contribution was valuable for chnical experiments and sound 
judgment. He compiled the first evidence indicating excess in sugars 
and starches as a cause of diabetes, but concluded that it could not 
be the most important cause, or many more persons and some entire 
races would have diabetes. He overthrew various current errors, but 
somehow convinced himself in painstaking experiments that diabetics 
may excrete large quantities of sugar in the sweat, as reported by 
several other authors. From the negative findings in necropsies, 
he regarded diabetes as generally a functional disorder. His most 
notable achievement was the demonstration, in three separate experi- 
ments on a single patient, of sugar excretion equalling exactly 60 per 
cent of the protein of the diet. "These facts, remaining constant under 
varied conditions, cannot be accidental; they seem much more to con- 
tain the law of the relation in which, in this individual on exclusive 
meat diet, the production and excretion of sugar stands to the quanti- 
ties of ingested meat." 

Frederick William Pavy" (1829-1911), in the year that he received 
his doctorate (1853), visited Claude Bernard. He soon became one of 
the latter's opponents on the glycogenic theory, and, in particular, 
overthrew Bernard's claim that the hepatic or right-heart blood of a 
fasting or meat-fed animal contains notably more sugar than the sys- 
temic or portal blood. He accepted Bernard's view that diabetes is 
essentially a disorder of the liver, but denied that the hver normally 
supplies sugar to the circulation, and maintained that sugar is trans- 
formed in passing the intestinal wall, that sugar reaching the circula- 
tion as such is non-assimilable, and that the formation of any large 
quantity of sugar by the liver during Ufe would make everybody 
diabetic. His theories were largely incorrect, but his experimental 
work was scrupulously careful and exact and still furnishes useful 

^' See article by Hopkins. 



HISTORY 29 

information. The study of diabetes was the dominant interest of his 
life; and though a clinician with a large diabetic practice, he has the 
credit of perceiving that progress could come only from fundamental 
physiological investigations. The flippant remark of Sir WilUam 
Gull,28 "What sin has Pavy committed, or his fathers before him, that 
he should be condemned to spend his life seeking for the cure of an 
incurable disease?" is a compliment to Pavy rather than to its author. 
Clinically, Pavy proved the transitory nature of the apparent benefit 
from opium. He took a step backward by ignoring the quantity of the 
diet aside from carbohydrate. He was among the first^' to make the 
following observation ((1), p. 167): "Another feature of peculiarity 
belonging to the complaint, is the inabihty that is experienced to ren- 
der the urine alkaline by the administration of the fixed alkalies and 
their vegetable salts. Although I have given the carbonate of soda to 
the extent of four drachms a day; the acetate of potash, half an 
ounce; the tartrate of potash and soda or Rochelles salt, six drachms, 
and even an ounce; and the citrate of potash, six drachms; yet, I 
have never succeeded in rendering the urine alkaline, or in any way 
approaching this character." 

Seegen was also prominent in the battle over the glycogenic hy- 
pothesis. He laid down the principle that every prolonged glycosuria 
should be considered an incipient diabetes. His therapy was retro- 
grade in two points: he ignored the total quantity of protein and fat 
ingested, and lie denied the value of exercise, in the belief that it was 
based on a false theory. 

Von Pettenkofer and Voit published the first study of the respiratory 
metabolism of a diabetic patient. They made the interesting remark 
that they dared not inflict much fasting on a diabetic, because of the 
great hunger and the difliculty of rebuilding lost tissue. Their work 
was originally supposed to show a subnormal oxygen consumption by 
the diabetic. Reynoso had previously attributed diabetes to dimin- 
ished respiration. Ebstein (1836-1912) devoted extensive labor to the 
attempt to prove that as CO2 inhibits the diastase of saliva, pancreatic 
juice, and organ extracts, so also it inhibits diastase in the living body, 

="8 Cf. Editorial, J. Am. Med. Assn., 1913, Ix, 1159. 

^'For earlier, less definite observations, cf. Griesinger, p. 59. 



30 CHAPTER I 

and that diabetes is due to abnormal diastatic activity resulting from 
subnormal production of CO2 in the tissues. In treatment he advised 
the usual diet, also carbonated waters. He (1) claimed priority as 
being the first to point out the danger of coma when antidiabetic diet 
is suddenly begun. He opposed inanition, but considered exercise 
beneficial through increased CO2 production. Schnee and a few others 
followed this doctrine. 

Kussmaul, a pupil of von Frerichs, in 1874 gave the first detailed de- 
scription of diabetic coma, distinguished it from pulmonary disease, 
uremia, and other terminal processes, called attention to the char- 
acteristic dyspnea, and from the physiological action of acetone ob- 
served in man and animals cast doubt on acetone intoxication as the 
cause of the condition. 

After Bouchardat, the most powerful impetus to the rigid dietetic 
treatment of diabetes came from Cantani (1837-1893). A pupil 
of von Jaksch, he was at once a clinician and an enthusiastic chemist 
and theorist. His preface preaches that, however great the achieve- 
ments of morphologic pathology, it can show only the form, and never 
the process at work; only chemistry can give the solution, and he pre- 
sents his findings as a beginning in the pathology of metabolism. His 
first chapter lays down the principle that metabolism is disturbed by 
excess of any constituent in the diet, and if the excess is prolonged, the 
disorder becomes permanent; diabetes and gout are examples. In an 
analysis of 218 careful case histories, he showed that carbohydrate had 
practically always predominated in the diet; but critics must observe 
that Cantani practised in Rome. He believed the greater frequency 
of the disease in Italy as compared with Germany and Austria to be 
due to centuries of over-rich carbohydrate diet. When nervous shock 
or other causes seem to bring on diabetes, he thought that the incipient 
disease was generally present before. He admitted that a primary 
predisposition must precede, because so many persons can live on 
excessive carbohydrate diet and never develop diabetes. He con- 
sidered the seat of diabetes to be in "the abdominal organs of diges- 
tion, the chylopoietic glandular organs" ( (l), p. 363). Atrophy of 
the pancreas present in some of his own cases and those in the litera- 
ture was interpreted by him as the result and not the cause of diabetes. 
He believed (p. 331) that sugar is mostly absorbed through the thoracic 



HISTORY 31 

duct and only a small portion enters the liver through the portal vein; 
and (p. 257) quoting Kiihne's 1868 text-book of physiological chemis- 
try against the glycogenic theory, he expressed surprise that a chemist 
like Pavy should believe that the liver could change sugar into glyco- 
gen. He thought it probable that the blood sugar in health fails to 
pass into the urine because burned in the epithelial cells of the kid- 
ney.'" Diabetic symptoms were attributed to the non-combustion of 
sugar and its circulation in excess. He claimed to show (pp. 274r-275) 
that the sugar of diabetic blood is a so called para-glucose, which is 
reducing but non-polarizing and non-assimilable; the kidneys trans- 
form it and excrete it in the urine as true glucose. He regarded ace- 
tone formation and coma as due to the digestive disorder, and as acci- 
dental in character. His treatment set an entirely new standard of 
strictness; this was the essential contribution made by Cantani. He 
isolated patients under lock and key, and allowed them absolutely no 
food but lean meat and various fats. In the less severe cases, eggs, 
liver, and shell-fish were permitted. For drink the patients received 
water, plain or carbonated, and dilute alcohol for those accustomed to 
Kquors, the total fluid intake being limited to one and one-half to two 
and one-half liters per day. For flavoring were permitted acetic and 
citric acids, and distillate of orange blossoms. Lactic acid was given 
regularly as the best substitute for carbohydrate and to aid digestion; 
Cantani deemed that by means of it he was enabled to keep patients 
on a more rigid diet than any of his predecessors. The quantity of 
protein was carefully limited; 500 gm. of cooked meat per day were 
considered enough for any diabetic, and 300 to 400 gm. sufl&cient to 
maintain strength. The value of vigorous muscular exercise was 
recognized, and it was proved by clinical tests that glycosuria was thus 
diminished or abolished without change in the diet. If the glycosuria 
was not otherwise controlled, fast-days were imposed, as often as once 
a week if necessary. On these days nothing was allowed but water, or 
sometimes bouillon three times a day. The protocols show a sharp 
drop in the glycosuria on fast-days.'^ The duration of this treatment 

'" This idea has lately been supported by Reicher, by Pierce, and by Woodyatt. 

'' Stokvis (1886) considered fast-days as having only experimental interest, 
stating that in Cantani 's records, the glycosuria returned promptly in every case 
and not one showed any clinical benefit. 



32 CHAPTER I 

is also a noteworthy step; the regular period was three months, and 
it was extended to six or even nine months if necessary to achieve 
sugar-freedom. After two months of absence of glycosuria, green 
vegetables were begun; and later wine, cheese, nuts, sugar-poor fruits, 
and finally small quantities of farinaceous foods were added. Notice 
was taken of the different tolerance for different forms of carbohydrate 
(p. 230). Glycerol'^ was found to produce a return of glycosuria in 
sugar-free patients (p. 258). The urine was analyzed daily during 
treatment, afterward once every week, then every two weeks. The 
least trace of glycosuria (p. 229) called for one or two months of abso- 
lute protein-fat diet. The patient who could return to moderate car- 
bohydrate diet was considered genuinely cured. If a more generous 
diet brought a return of glycosuria, it was regarded not as a relapse 
but as a fresh attack, caused by the same excess in carbohydrate which 
produced the diabetes in the first place. This determined insistence 
upon sugar-freedom was Cantani's best contribution; but it was 
marred by faults which have persisted since, namely, the high calory 
fat diet, the beUef (p. 231) that gain in weight is one of the most 
important benefits, and (p. 386) that a slight glycosuria is preferable 
to undernutrition. Regarding his failures, Cantani believed (p. 356) 
that as long as the pancreas alone, or perhaps the stomach alone, is 
diseased, the diabetes is curable in all cases, but after the liver is in- 
volved a cure is impossible. He acted (pp. 369-370) on the theory of 
sparing a weakened organ. He held the modern view that diabetes 
is a unit, and that the varying cases represent different degrees or 
stages, not different diseases. He distinguished two groups: cases in 
which sugar disappears on meat diet, and those in which it does not dis- 
appear. He judged that the lowered temperature and the slowed 
respiration were evidence of a diminished metabolism in diabetes. He 
thought (p. 203) that diabetes is better borne by fat than by thin people 
because of their lower metabolism, and that the greater severity of dia- 
betes in young persons and children is explained by the higher metab- 
olism. The diminution of glycosuria on fasting was held (p. 190) 

^^ Glycerol in the treatment of diabetes was first used by Basham {Lancet, 
January, 1854). It was especially advocated by Schultzen (Bed. klin. Woch., 
1872, No. 35) on the basis of an erroneous chemical theory. Cf. Naunyn ( (5), p. 
441). 



msTOEY 33 

to prove that the diabetic's own tissues are not convertible into sugar, 
though the glycosuria on meat diet shows that sugar can be formed from 
ingested protein. The description (p. 302) of a case of cerebral tumor, 
causing paralysis of the optic and oculomotor nerves, with poljTiria 
and 3 per cent glycosuria, which cleared up after several months, while 
the tumor progressed and caused death, may now receive probable 
interpretation at the first mention of h5^ophyseal diabetes. The 
infectious nature of tuberculosis being unknown, the development of 
pulmonary tuberculosis in a diabetic was to Cantani (pp. 113, 233) a 
sign that the glycosuria could never be abolished, that the breakdown 
in metabolism was hopeless, and death inevitable. 

The authors who described gross lesions of the pancreas in diabetic 
necropsies are named by Bouchard ( (1), p. 171) as follows: Cawley, 
Elliotson, Bright, Bouchardat, Griesinger, Hartsen, Fles, von Reck- 
linghausen, von Frerichs,Klebs, Harnack, Kuss, Cantani, Silver, Fried- 
reich, Haas, Lecorche, Lancereaux.^' Zimmer in 1867 supposed that 
carbohydrates are normally split to lactic acid in the intestine, but in 
the absence of pancreatic juice the process stops at the stage of glucose, 
with resulting glycosuria; but later he considered diabetes as a defect 
of muscular metabolism. Popper (1868) assumed that diabetes is due 
to lack of pancreatic juice, causing disturbance in fat digestion and 
secondarily in glycogen storage in the liver. Lancereaux, a pupil of 
Claude Bernard, described a form of diabetes characterized by sudden 
onset, marked emaciation, polyphagia and polydipsia, characteristic 
feces, and early death. He correctly interpreted this complex as 
evidence of a pancreatic lesion. Hirschfeld later described similar 
cases. But Lancereaux and his pupil Lapierre proceeded to assume 
that all diabetes with emaciation is due to a gross pancreatic 
lesion; to this diabete maigre or pancreatic diabetes they opposed the 
type of diabete gras or fat diabetes, supposedly not pancreatic in ori- 
gin. They also added later a "constitutional" or "arthritic" diabetes 
and a "nervous" diabetes. This classification has been generally dis- 
credited but still persists to some extent in France. 

Baumel was the first to set up the hypothesis that all diabetes is 

''Other literature is given by Sauerbeck, Rosenberger (p. 206), and Allen, 
( (1), Chapter 21). 



34 CHAPTER I 

pancreatic in origin. When no gross or microscopic alterations could 
be found, he assumed the presence of a nervous or circulatory disturb- 
ance. Lack of pancreatic diastase was imagined to be the essential 
factor, and the inhibition of secretion of pancreatic juice by stimula- 
tion of the central end of the vagus was considered illustrative of 
what might occur in diabetes of functional origin. 

Bouchard followed Lancereaux in regarding diabetes with emacia- 
tion as pancreatic in source. He upheld the doctrine of diminished 
utilization as opposed to Bernard's view of simple overproduction of 
sugar, and he classified diabetes among the diseases due to retardation 
of metabolism. 

Friedrich Theodor von Frerichs (1813-1885) published a work of 
careful objective description, free from theories and preconceptions, 
based on an experience of 400 cases and 55 necropsies. His preface 
' states that he began with the exact science chemistry, passed thence to 
physiology, and thence to the clinic, and writes now in the autumn of 
life to present the fruits of nearly forty years' experience. The thor- 
ough study and analysis of his cases, clinically, chemically, and patho- 
logically, constitute the author's chief merit in extending the knowl- 
edge of diabetes. He distinguished three forms of sudden diabetic 
death; viz., cardiac failure, collapse, and the Kussmaul coma. To- 
day it seems probable that all three are manifestations of acidosis. 
By clinical experiments he made the acetone intoxication theory im- 
probable. Ehrlich, with von Frerichs, investigated the glycogen in 
'diabetes, not only post mortem but by liver puncture during life. 
Ehrlich likewise discovered the so called glycogenic degeneration of 
the renal tubules in diabetes. 

Richard Schmitz of Neuenahr was the first to give conclusive dem- 
onstration of complete recovery in a few cases of diabetes. Also, 
among his 2320 cases he observed 26 in which the diabetes, in ab- 
sence of any other discoverable cause, seemed so definitely to come 
on after close association with another diabetic (through marriage or 
otherwise) as to suggest an infectious transmission. Senator, Oppler 
and C. Kiilz, and others have made it reasonably certain that such 
cases represent mere coincidence. 

Rudolph Eduard Kiilz (1845-1895) was a similar and even more 
notable example of a painstaking, unbiased investigator. To him 



HISTORY 35 

diabetes was a mystery, toward the solution of which theorizing was 
futile and only the gathering of the most complete and exact data 
possible could be valuable.'^ In journal articles Kiilz published many 
laboratory investigations, especially concerning glycogen. Also, 
he discovered the oxybutyric acid in diabetic urine simultaneously 
with Minkowski, and was first to observe it to be levorotatory. His 
clinical experience of twenty-five years covered 1 100 carefully studied 
cases of diabetes, of which 711 were chosen for publication. Probably 
no other man ever did so much to clarify the subject by proving all 
things and holding fast that which was good. His experiments were 
the last which finally ended the error of excess of fluid output over 
intake in diabetes. He found sugar absent from the sweat. He 
showed the uselessness of lactic acid and the harmfulness of glycerol. 
He proved the absolutely negative effects of various drugs, notably 
sodium bicarbonate and arsenic, for diminishing glycosuria, aside from 
the illness and digestive upsets produced; this lesson of KUlz con- 
cerning Fowler's solution still needs to be learned by many today. 
He demonstrated with exactness that Carlsbad water has no effect 
upon diabetes. Although no valid evidence has ever shown that any 
kind of water anj^where has specific influence upon diabetes, this 
superstition is still so prevalent among both physicians and patients 
that diabetics continue to flock by thousands to mineral springs like 
pilgrims to medieval shrines. Kiilz disapproved of the methods of 
Bouchardat, who jumped at truths without pausing to prove them; 
and much of his constructive work actually consisted in establishing 
on a substantial basis the suggestions of the brilliant Frenchman. He 
tested the tolerance of many patients for many forms of carbohydrate, 
finding ( (2), p. 528) that the assimilation is better for green vege- 
tables than for the equivalent of starch in other forms; and that lac- 
tose, levulose, and even cane sugar are often better borne than glu- 
cose, but results are variable and levulose is often harmful and utilized 
no better than starch. He was unable to formulate any fixed rule 
whether glycosuria is increased by alcohol or not. By careful com- 

^* Preface to "Beitrage:" "Main Bestreben ging vor Allem dahin, moglichst 
exacte Beobachtungen zu liefern. In wieweit mir dies gelungen ist, in wie weit 
diese Untersuchungen geeignet sind, unsere Kenntnisse von diesem in vieler 
Beziehung noch so rathselhaften Leiden zu erweitern, mag die Kritik entscheiden." 



36 CHAPTER I 

parison between periods of days of rest and corresponding periods 
with exercise, he reached the conclusion that e!xercise is beneficial in 
strong patients with mild diabetes; in severe diabetes, where sugar 
is excreted on carbohydrate-free diet, exercise may diminish glyco- 
suria, sometimes only transitorily, or it may have no effect; and 
in weak individuals with severe diabetes, there was no benefit 
from exercise.'^ The great experience of Ktilz was probably the most 
powerful factor in establishing the modern view of the unity of dia- 
betes. His cases were classified in three groups; first, a mild group, 
becoming sugar-free on strict diet; second, a "mixed" or intermediate 
group; and third, the group of severe cases, with glycosuria continu- 
ing on restricted diet. The numerous careful case records showed 
such an abundance of gradations and transitions between these groups, 
from the mildest to the most severe, that fixed distinctions between 
types of diabetes were shown to be impossible. Kiilz made no use of 
undernutrition or fasting. He treated severe cases by gradual with- 
drawal of carbohydrate to avoid coma, reduced protein not below 110 
gm. daily, and was one of the first to calculate diets according to the 
caloric requirement. He was the first to introduce the practice of 
systematically testing the carbohydrate tolerance of each patient. 
Rumpf" claims as the greatest merit of the Kiilz system the inaugu- 
ration of individually planned diets instead of indiscriminating general 
rules. Notwithstanding the universal adoption of this plan by special- 
ists and the better informed physicians, it is a regrettable fact that 
the majority of the profession have not yet come up to the standard of 
Kiilz, and the majority of diabetics still receive treatment by means of 
printed hsts of "allowed" and "forbidden" foods. Kulz founded a 
numerous and influential school. Of the three editors of his posthu- 
mous work, Aldehoff is known for various clinical and experimental 
studies, Sandmeyer chiefly for the diabetes produced in dogs by pan- 
creatic atrophy, and Rumpf as a prominent clinician, who made early 
studies of dextrose-nitrogen ratios in human patients (1, 2, 3), and 

^' This was not only the most thorough investigation of exercise in human dia- 
betes, but also an important independent discovery, for Kiilz did not know of any 
previous use of exercise till after completion of his experiments. 

'« Preface to Kiilz (2). 



HISTORY 37 

first (3) warned against loss of body fluid as an important factor in 
bringing on coma. 

Joseph Friedrich von Mering (1849-1908) was trained under von 
Frerichs and Hoppe-Seyler. Though a clinician of high standing, his 
fame rests upon his numerous experimental works, among which may 
be mentioned his metabolism studies with Zuntz, the discovery (1886) 
of phloridzin glycosuria, and the discovery with Minkowski (1889) 
of pancreatic diabetes in dogs. 

Bernhard Naunyn (born 1839) was the pupil of Lieberkiihn, Reich- 
ert, and von Frerichs. Though the author of a number of researches, 
they include no important discovery. His position as the foremost 
diabetic authority of the time rests upon his influence for the advance- 
ment of both clinical and experimental knowledge; upon his judgment, 
his teaching, and his pupils; upon the fact that from his great Strass- 
burg school have come the soundest theories, the most fruitful inves- 
tigations, and the most effective treatment. In birth, it is to be noted 
that Naunyn preceded Kiilz, and was only two years younger than 
Cantani. He came into this field in the pioneer period when the 
principle of dietetic management was generally recognized, but the 
average practice, especially in regard to severe cases, was still a mass 
1 of ignorance and inefficiency. As late as 1886, Naunyn (1) stood as 
the champion of strict carbohydrate-free diet in a German medical 
congress where most of the speakers opposed it. As one of the few 
early German followers of the Cantani system, he maintained its 
feasibility and ultimate benefit, and locked patients in their rooms for 
five months when necessary for sugar-freedom. With experience, he 
gradually introduced modifications, until the rigid and inhuman 
method, which a majority of physicians and patients would never 
adopt, became a rational individualized treatment, with a diet reckoned 
according to the tolerance and caloric requirements of each patient. 
The work of various pupils requires mention in this connection. Im- 
portant investigations of metabolism established the basis for this 
treatment, the inost notable being that of Weintraud, who proved that, 
instead of having an increased food requirement, diabetics could main- 
tain equilibrium of weight and nitrogen on a diet as low as or a little 
lower than the normal. Minkowski discovered with von Mering the 



38 CHAPTER I 

diabetes following total pancreatectomy in dogs," and established 
the doctrine of the internal secretion of the pancreas, as well as the 
first clear conception of a dextrose-nitrogen ratio. After the early 
acetone investigations and Gerhardt's discovery of the ferric chloride 
reaction had failed to reveal the cause of coma, the Naunyn school 
accomplished almost the entire development of the subject of clinical 
acidosis in the following sequence. Hallervorden (1880) discovered 
the high ammonia excretion, confirming an earlier discredited observa- 
ton of Boussingault. Stadelmann (1883) established the presence in 
the urine of considerable quantities of a non-volatile acid supposed to 
be a-crotonic, correlated the condition with Walter's previous acid 
intoxication experiments, and theoretically suggested the treatment 
with intravenous alkali infusions. Minkowski proved the excreted 
acid to be /S-oxybutyric, and demonstrated the presence of this acid 
in the blood and a diminished carbon dioxide content of the blood. 
He, also Naunyn and Magnus-Levy, applied the alkali therapy in 
practice, and the latter carried out chemical and metabolism studies 
which made him the recognized authority in this field. Naunyn intro- 
duced the word acidosis, saying in definition ( (4), p. 15): "With this 
name I designate the formation of /8-oxybutyric acid in metabolism." 
The Naunyn school have consistently maintained that this acidosis 
is an acid intoxication in the sense of Walter's experiments. They 
demonstrated striking temporary benefits from the alkali therapy, 
particularly in diminishing the danger of the change from mixed to 
carbohydrate-free diet; but the practical results were never equal to 
the theoretical expectations. With Naunyn, also, acidosis became 
the principal criterion of severity for the clinical classification of cases. 
As regards other theories, the Naunyn school have upheld the deficient 
utilization as opposed to the simple overproduction of sugar in dia- 
betes. They have clearly recognized the necessary distinction be- 

" This is commonly supposed to have been an intentional following up of the 
observations of Cawley, Bouchardat, and others. But according to Dr. A. E. 
Taylor (personal conmumication) the epoch-making discovery was accidental. 
Dogs depancreatized for another purpose were in a courtyard with other dogs. 
Naunyn, perhaps mindful of the part played by insects in the history of diabetes, 
asked, "Have you tested the urine for sugar?" "No." "Doit. For where these 
dogs pass urine, the flies settle." 



HISTORY 39 

tween diabetes and non-diabetic glycosurias." Naunyn was next 
after Klemperer to recognize clinical renal glycosuria. Though 
observing that "the course of the disease is as variable as can be 
conceived," he nevertheless upholds the essential unity of diabetes, 
finding in heredity a link which often connects cases of the most varied 
types. In regard to the etiology, he considers that "it is certain that 
disease of. the nervous system and of the pancreas can produce dia- 
betes;" other causes seem more doubtful. The nervous disorder 
supposedly acts indirectly by setting up a functional disturbance in 
the pancreas or other organs directly concerned. Underlying every-; 
thing in most cases is, in his opinion, the diabetic "Anlage" or inherited; 
constitutional predisposition. Naunyn has particularly supported; 
the conception of diabetes as a functional deficiency, to be treated by 
sparing the weakened function. He wisely emphasized the impor- 
tance ( (5), p. 391) of doing this at as early a stage as possible, before 
the tolerance has been damaged and the glycosuria has become "ha- 
bitual." His plan of treatment is to withdraw carbohydrate gradually, 
giving large doses of sodium bicarbonate in cases with acidosis as ii, 
further precaution against coma. A brief increase of the ferric chloride ; 
reaction is not allowed to interfere with the program. When the 
glycosuria is successfully cleared up, the aim ( (5), p. 396) is if possible 
to place the patient on a Rubner diet, representing 35 to 40 calories ; 
per kilogram of body weight and about 125 gm. protein (pp. 407-. 
408), carbohydrate being gradually (p. 415) added and then kept (p., 
416) at a figure safely below the tested tolerance. The views con-, 
cerning exercise (p. 432) agree with those of previous authors; brisk 
walking, etc., is found beneficial; but overexertion is harmful, especi- 
ally in severe cases; and some patients seem to do best on a rest cure. 
When sugar-freedom is not attained on simple withdrawal of carbo- 
hydrate, protein may be reduced as low as 40 to 50 gm. daily ( (4), p. 
22) and the calories also diminished, since ( (4), p. 22; (5), p. 397) 

''Magnus-Levy {(2), p. 8), concerning pancreas-diabetes: "Dieser Diabetes 
ist der einzige experimentelle, der tatsachlich als Diabetes zu bezeichnen ist." 
Naunyn ( (2), p. 3130) : "Einen Diabetes melitus haben die Experimentatoren vor 
Minkowski und von Mering nie erzeugt . D er sogenannte Kurare, der Kohlenoxyd, 
etc., der Stichdiabetes und selbst der Meringsche Phloridzindiabetes, sie alle tra- 
gen diesen Namen mit Unrecht." 



40 CHAPTER I 

diabetics may remain in equilibrium on as little as 25 to 30 calories 
per kilogram. When necessary as a final resort, temporary under- 
nutrition may be employed ( (S), pp. 392, 409) ; but prolonged under- 
nutrition or the loss of more than 2 kilos weight should be avoided 
( (4), p. 15). Loss of weight continuing over the third week of treat- 
ment requires adding carbohydrate and abandoning the attempt to 
stop glycosuria ( (5), p. 414). Occasional fast-days are advised if 
necessary ( (5), p. 409), but only when previous treatment has reduced 
the glycosuria below 1 per cent; otherwise their effect is indecisive 
( (5), p. 426). It is stated ( (5), p. 425) that such fast-days are prac- 
ticable for even the severest cases, and heavy acidosis is not a contra- 
indication (p. 426); the ferric chloride reaction may diminish on a 
fast-day (p. 414). Naunyn has not stated what hmitations apply to 
the use of such occasional fast-days, but Magnus-Levy ( (2), p. 67) 
stipulates that they must never be more frequent than one in eight or 
ten days, and in very thin patients must be avoided altogether. Fast- 
ing is nowhere recommended as a treatment for coma by Naunyn. 
On the contrary, when restriction of diet produces really threatening 
symptoms, his plan is to add carbohydrate and give up the attempt to 
abolish glycosuria '( (2), p. 3144; (5), p. 414). Even the persistence 
of a very heavy ferric chloride reaction longer than two or three days 
is a signal for adding carbohydrate (p. 425). The treatment for im- 
pending coma consists in maximal doses of bicarbonate and the free 
use of carbohydrates, especially milk ( (4), p. 28; (5), pp. 350, 351; 
also Magnus-Levy, (2), p. 77). Naunyn had some conception of 
limiting the total metaboUsm ( (4), p. 14), but meant by it only a bare 
maintenance diet, or the sUght and temporary undernutrition men- 
tioned above. Naunyn ( (4), p. 13) states that fat does not appreci- 
ably increase glycosuria; elsewhere ( (6), p. 741) that in very severe 
cases it may slightly increase glycosuria; Magnus-Levy ( (2), p. 21) 
that it never gives rise to glycosuria. Like others, Naunyn considers 
that fat is the chief food for the diabetic ( (5), p. 449) ; that the intro- 
duction of fat is the most important art in diabetic cookery ( (6) , p. 741) . 
He uses it to complete the full number of calories when other foods 
are restricted ( (5), pp. 408, 447); this apphes even to the severest 
cases on carbohydrate-free diet with strict limitation of protein, where 
accordingly much fat is given (p. 424) ; his principal care is that the 



HISTORY 41 

patient shall take enough of it (p. 395) ; the only reason for limiting 
the quantity is the danger of indigestion (pp. 395, 424), except when 
coma impends, in which case fats are replaced by carbohydrates, and 
butter is especially shunned because of its content of lower fatty, 
acids (p. 350). Even when sugar-freedom is attainable, certain cases 
are believed to show an inherent progressive downward tendency 
( (2), pp. 3135-3136; (5), p. 390). Concerning patients emaciated 
down to 50 kilograms, with heavy ferric chloride reaction and the 
usual accompaniments, it is said (p. 425) : "In the face of these great 
difficulties and dangers, which accompany the energetic management 
of these very severe cases, the prospects of being successful in per- 
manently removing glycosuria are in general not very great, and usually 
one will be content with a limitation of it which suffices to bring the 
patient into nutritive equilibrium, that is, down to 60 to 80 gm. sugar 
in 24 hours." 

Lenne of Neuenahr is known chiefly for his advocacy of low 
protein diet. His plan is to reduce the nitrogen intake until the out- 
put falls to his so called "normal" figure; viz., 0.37 gm. urea or 1.1 gm. 
absorbed protein per kilogram of body weight (about 1.3 gm. per kilo 
in the diet). Carbohydrate is also limited, but the protein restriction 
is considered more important. He classifies cases into four groups: 
those in which (1) the glycosuria ceases on diminution of protein 
without diminution of carbohydrate and the protein requirement 
falls to 1.1 gm. per kilo; (2) this result is achieved only by reducing 
carbohydrate as well as protein ; (3) limitation of protein and carbo- 
hydrate stops glycosuria but the protein requirement never falls to 
1.1 gm. per kilo; (4) glycosuria continues and nitrogen remains high 
in spite of complete withdrawal of carbohydrate and strict limitation 
of protein. He believes in simple overproduction of sugar without 
impairment of utilization as the explanation of diabetes, and in the 
correlated doctrine of sugar formation from fat. He states ( (1), p. 
82) that it is not necessary to assign any upper limit for fat, since 
appetite and digestion set the limit; later (2) he speaks in favor of 
fat restriction, but only in the sense that the diet should be adequate 
but not excessive. He does not limit fat even for the sake of acidosis, 
since he disbelieves in the acid intoxication theory of coma, and cites 
( (3), pp. 252-253) the example of a patient whose urine became free 



42 CHAPTER I 

from diacetic acid on carbohydrate abstinence, insufficient protein, 
and excess of fat. He insists on abolishing glycosuria and hyper- 
glycemia if possible, and opposes ( (l), p. 74) von Noorden's opinion 
that some diabetics, especially the elderly, can be indulged in eating 
as long as sugar is liot excreted above 20 gm. daily. Nevertheless he 
refuses (p. 83) to prolong absolute carbohydrate-free diet for a week or 
over. For stubborn glycosuria he has used fast-days, but prefers to 
avoid any complete abstinence. His protocols show the benefits of 
protein reduction, but also indicate the failure of the method in numer- 
ous cases of only moderate severity. 

It is desirable at this point to introduce a digression, for the purpose 
of considering the so called "carbohydrate cures" as a group. 

It will be observed that carbohydrate has been the touchstone of diabetic 
therapy since the time of Rollo. All the orthodox theories have agreed in holding 
it as the one offending substance, and a large proportion of physicians today still 
conceive of dietotherapy as limited to prescribing a list of carbohydrate-poor 
foods. On the other hand, the vast majority of diabetic patients have (following 
or defying advice) never undergone rigid deprivation of carbohydrate for any long 
time, the specialists of highest repute have granted it in the later stages of the more 
severe cases, and there has grown up a line of treatment characterized by diets 
heavy in carbohydrate. 

The milk diet is historically first. According to Stokvis, milk was recommended 
for diabetes by almost all authors in the eighteenth century. The Karell cure, pub- 
lished in 1866 and still well known in the treatment of obesity and other conditions, 
was a diet limited strictly to 60 to 200 cc. of skim milk four times daily. Rich- 
ardson credits "Dr. Smart of Edinburgh" with priority in the use of a formal 
"milk cure" in diabetes. A skim milk treatment was advocated by Donkin (1869) 
on the claim that it was pleasanter than the Bouchardat plan and also more effec- 
tive, as casein is better assimilated than other proteins, and lactose than other 
forms of carbohydrate. Balfour, Oettinger, Winternitz and Strasser, Maurel, 
Landouzy and Cottet, and numerous others championed the milk treatment, but 
Kiilz, von Frerichs, and most authorities condemned it. Strasser advised three 
days of milk, then three days of strict diet, and so on alternately — a schedule 
which might rank high among carbohydrate "cures." 

Prasad asserts that in India a diet chiefly of milk permits mildly diabetic patients 
to live fifteen or twenty years. Naunyn considers that it is hard to get along with- 
out milk in treating diabetes, and that milk "cures" are often beneficial. He and 
his followers have used it as the principal means to ward off acidosis. Guelpa's 
use of milk is mentioned later. Recently (1915) Farges has taken up the original 
belief concerning milk, holding that not only is lactose perfectly assimilated in mild 
diabetes, but that it actually improves the tolerance for other carbohydrates. 



HISTORY 43 

Sour milk and its commercial preparations have been used to some extent, but 
according to von Noorden ( (1), p. 315) only 10 to IS per cent of the sugar is de- 
stroyed in the natural curdling, and souring beyond this point makes the taste too 
unpleasant for use; he therefore rates sour milk as neither bettfer nor worse than 
sweet milk. The status of the typical milk cure as a form of undernutrition treat- 
ment is universally recognized. 

Second chronologically was the treatment of von During of Amsterdam, often 
incorrectly styled the "rice cure." The first edition of this author's book appeared 
in 1868, the fifth edition in 1905. He limited his patients to three or four meals 
daUy, representing a total of 80 to 120 gm. of any cereal (frequently rice, least often 
oatmeal because of its tendency to ferment), up to 250 gm. meat, moderate quan- 
tities of stewed fruits, and small allowances of stale bread, milk, and wine. His 
general position was a protest against overeating and luxurious living, and a "back 
to nature" attempt in food, exercise, and general hygiene. He was a pioneer in 
sanitarium discipline and restriction of the total diet. One interesting trick was 
his use of ice and ice-water to combat polyphagia. He was a zealot in his beliefs, 
but frankly acknowledged numerous failures. His method may be interpreted as 
a mixed ration rather low in protein and calories, not infrequently proving prefer- 
able to the protein-fat excess of which his earlier contemporaries were signally 
guilty. 

Dujardin-Beaumetz (1889) first recommended potatoes for diabetics in quanti- 
ties below 100 gm., because they contained less carbohydrate than the usual gluten 
bread. Mosse (first publication 1898) believed potatoes to be far superior to other 
forms of carbohydrate for assimilation in diabetes, and attributed the supposed 
virtue to their content of potassium, and perhaps also of organic acids, traces of 
manganese, or oxidases. He gave as much as 1500 gm., or in polyphagia 3000 
gm., not as occasional "cures" but as regular additions to the daily diet. His 
records and graphic charts of comparisons between potatoes and bread reveal in 
many instances a much smaller quantity of carbohydrate in the potato diets; in 
other cases the quantity of carbohydrate was kept equal, but it is doubtful if 
patients taking such large quantities of potatoes would eat as much of other kinds 
of food as when taking bread. The alleged advantage of potatoes is thus readily 
explained. Also the treatment was very bad throughout, for though the cases were 
mild, there was no pretense of stopping glycosuria, which was high even in the cases 
showing the imagined benefit. The treatment thus poorly founded gained wide- 
spread adoption only in France. Rathery refers to the numerous patients there 
who complain of glycosuria uncontrollable by strict diet, when inquiry shows that 
they are consuming potatoes liberally in the belief that they are harmless and 
beneficial. He finds it necessary to point out the smaller percentage of starch in 
them as compared with bread or cereals. Labbe, by testing a series of mildly 
diabetic patients with allowances slightly above their tolerance, composed a list of 
carbohydrates in descending order of assimilation, as follows: potato, oatmeal, 
macaroni, chestnuts, rice, beans, lentils, peas, milk, bread, sugars. Linossier, 



44 CHAPTER I 

discussing certain of these papers, properly called attention to the lower protein 
and calories of the potato diets. The facts concerning potatoes are fully explained 
by their relatively low food value, in that they carry little protein or fat and only a 
fraction of the carbohydrate percentage of bread or cereals, while their bulkiness 
tends to diminish the consumption of other foods. They are a higher homologue 
of the green vegetables, and may be used correspondingly in the milder grades of 
diabetes. 

Von Noorden made the chance observation that certain patients showed marked 
improvement in their diabetes, even to cessation of glycosuria, when placed be- 
cause of digestive disturbances on a diet of oatmeal gruel. It is probable that such 
rations were rather low in protein and calories. In 1902 he announced his formal 
"oat-cure." Though there were ahready facts in the literature to indicate the true, 
explanation, the diminution or disappearance of glycosuria on change from strict 
to carbohydrate-rich diet impressed von Noorden and the contemporary medical 
World as an astounding and mysterious phenomenon. Naunyn held a skeptical 
attitude throughout . He favored the untenable hypothesis of intestinal fermenta- 
tion supported by his pupil Lipetz, but he also (4A) early classed all carbohydrate 
"cures" together and declared that the essential benefit lay in undernutrition. 
Kolisch's correct suggestion of the importance of a low .protein intake was sup- 
posedly disproved by the incorporation of eggs and vegetable protein in the oat 
diet. Falta and others employed smaller quantities than the established 250 gm. 
of oatmeal; but none perceived that the value of the "cure" diminished as the 
quantities of foods were increased. The therapeutic endeavor was to make up a 
full Voit diet to avoid undernutrition, depending on the supposed virtues of oat- 
meal and special proteins to achieve assimilation. DiflFerences in the manner of 
cooking, and even distinctions between brands of oatmeal, were asserted and ac- 
cepted. The experimental goal was to discover the reason for the superiority of 
oatmeal over other carbohydrates, and thus much fruitless labor was spent upon 
oat extracts, digestion, renal permeability, and intestinal bacteriology. Thus the 
entire clinical and experimental development of von Noorden's primary observa- 
tion followed mistaken lines. Blum in 1911 attacked the foundation of the error, 
by comparative tests showing the equal assimilation of oatmeal and other carbo- 
hydrates when administered to diabetic patients imder identical conditions. He 
likewise overthrew the perplexing claim that the severe cases are the ones that 
assimilate oatmeal best; and it is now generally recognized (cf. Magnus-Levy (2), 
p. 70) that cases doing well on carbohydrate "cures" are essentially mild even 
though they may have appeared severe. Also in 1911, Klemperer showed that 
even sugar behaves similarly when given in divided doses. The von Noorden 
school has maintained, with diminishing force, that oatmeal possesses some degree 
of superiority, and has arranged a scale of assimilability, in which bananas and 
barley stand next to oatmeal, and wheat and rice are at the lower end. The litera- 
ture up to 1913 permitted no positive conclusion. Minkowski (4) , in a sweeping crit- 
icism of the Vienna doctrines, acknowledged the benefits of the oat cure. Magnus- 



HISTORY 45 

Levy added his experience in support of the relatively better assimilation of oat 
starch. It has since become clear that the mixed or indecisive clinical observations 
of von Noorden, Lampe," Werbitzki, Piskator, Richartz, Weiland, and other 
authors previously referred to furnish no sound evidence of any peculiar assimila- 
bility of oatmeal. On the contrary, accurate.comparative tests by Petersen, Wolff, 
and Falta have fuUy confirmed Blum's position. Jastrowitz found complete simi- 
larity between oats and wheat in experiments on totally and partially depan- 
creatized dogs. Csonka lately proved the equal and complete elimination of the 
carbohydrate of wheat and oats as glucose by phloridzinized dogs. The absence 
of any specific ease of assimilation of oatmeal by human patients has been demon- 
strated in the blood sugar investigations of Schirokauer, Severin, Lamp6 and 
Strassner, Wolf and Gutmann, and Menke, and in the studies of respiratory 
metabolism by Schilling, Roily, Roth, Joslin (2), and Allen and DuBois. 

The buckwheat (Alvord), raisin, and other sporadic "cures" require no special 
discussion. All the early carbohydrate treatments laid stress on the restriction to 
only one form of starch, but the benefit of such limitation was always incompre- 
hensible and is now recognized as imaginary. The later recommendations offer 
greater variety. Labbe has introduced a "dry legume cure," with a diet of 300 
gm. beans (including lima, soy, or other varieties), peas, or lentils, 150 gm. butter, 
3 to 6 eggs, 3 to 6 aleuronat or gluten cakes, green vegetables, and wine. The 
main thing avoided is meat. Falta, having renounced his old allegiance, now 
uses "mixed cures" planned after the oat cure except that monotony is avoided by 
means of alternation of all sorts of carbohydrate foods, with addition of green 
vegetables. 

The rationale of the carbohydrate "cures" appeared mysterious when diabetes 
was regarded as a deficiency of carbohydrate assimilation, but becomes clear with 
the imderstanding of diabetes as a general disorder of nutrition. Most of the diets 
represented some degree of undernutrition. In the oat cure, this was attained by 
the preceding and following vegetable or fast-days, adopted from Bouchardat, 
Cantani, and Naunyn. Temporary relief from the overload of protein and fat 
diet was afforded by the substitution of an excess of carbohydrate. The experi- 
ence showed that the latter is, at least for short periods, often less injurious and 
dangerous than the former. The successful results demonstrated the surprisingly 
high tolerance still retained in a large proportion of diabetic cases heretofore 
classed as severe. The invariable failure encountered in truly severe cases fol- 
lows as a simple corollary to the defim'tion, since the nature of severe diabetes 
involves inability to metabolize such quantities of carbohydrate, protein, and fat. 

Aside from the carbohydrate "cures," there have long been practi- 
tioners of higher and lower degree who have upheld the opposite 
of Rollo's animal diet, namely, a pure vegetarian diet. Harley em- 
ployed it for cases of a certain type. Kolisch may be mentioned as 
the principal champion of this system. He argues that diabetes does 



46 CHAPTER I 

not consist in a lowered tolerance for carbohydrate, because a small 
quantity of carbohydrate often causes less glycosuria than a large 
quantity of protein. He regards the disorder as an overproduction of 
sugar, derived from unknown compounds in the tissues. The improve- 
ment of tolerance on carbohydrate-free diet, also the cessation of 
glycosuria in cachexia observed by Cantani and Naunyn, are explained 
as due to impoverishment in sugar-forming material. Food, especially 
protein, is supposed to irritate the tissues so as to stimulate sugar 
formation. Therefore the author reiterates Bouchardat's advice, 
"manger le moins possible," and particularly restricts protein. He 
regards fat as the food which sets up the least stimulus to sugar for- 
mation and which never gives rise to glycosuria ( (1), p. 248). He 
enforces vegetarianism, because patients are thus kept in equilibrium 
on 20 to 25 calories per kilogram of weight with a diet bulky enough to 
satisfy, and because he believes that this maintenance requirement is 
lower than on animal food, that vegetable protein has a superiority 
over animal protein in contradiction to the caloric theory, and that the 
vegetable diet is intrinsically less irritating to the diabetic process. 
Milk is regarded as somewhat similar. Fast-days are supposed to 
benefit through absence of food irritation, but they are held ( (1), p. 
252, and elsewhere) to have little practical value, because their effect 
is transitory and glycosuria always returns. Kolisch (2) makes a 
trenchant criticism of the Kulz method of testing tolerance, objecting 
that this shows merely the result of adding relatively small quantities 
of carbohydrate to large quantities of protein and fat. Instead, he 
advocates trying various combinations of foods, and choosing the one 
which permits maintenance on the lowest number of calories, also the 
taking of as much carbohydrate as possible without harm. Here a 
critic will necessarily ask for a definition of the phrase "without harm." 
Von Noorden ( (1), pp. 369, 372) calls attention to the phenomenon 
studied by Leo, Rosenfeld, and Kolisch, that up to a certain point 
many diabetics assimilate more carbohydrate as the quantity ingested 
is increased (paradoxical law) ; the practice of giving such a ration as 
will cause the greatest possible combustion of carbohydrate is called 
the method of Rosenfeld and Kolisch; von Noorden opposes this 
method for mild or moderate cases, but endorses it for severe cases. 
Roubitschek and Gaupp are among the recent advocates of this "best 



HISTORY 47 

oxidation level" program, naming Klotz also in support of it. This is 
one phase of the method of the so called "carbohydrate balance," under 
which physicians everjrwhere have been greatly concerned over the 
relation between the quantity of carbohydrate ingested and the quan- 
tity of sugar excreted, and, especially in threatening acidosis, have 
juggled the diet in every possible way to make the former greater than 
the latter. The method has also been used very widely and by the 
highest authorities for the sake of mere comfort and temporary well- 
being of the patients; for example, von Noorden's advice, criticized 
above by Lenne; the advice of Naunyn ( (4), p. 20) that not more 
than 0.5 per cent glycosuria is allowable in mild cases; and the state- 
ment of Magnus-Levy ( (2), p. 67) that the advantage of 100 gm. 
bread in the diet is worth the excretion of 20 or 25 gm. sugar as long as 
no complications are present. This entire method is fundamentally 
vicious and in the end defeats every purpose for which it is employed. 
On the other hand, there is interest in the view of Kolisch, similar to 
that of Lenne, that the patients with milder diabetes are injured by 
heavy protein-fat diet, even though glycosuria and other s3anptoms 
are absent; and that the ultimate consequence is that they progress 
downward and later show the severe form. For such cases Kolisch 
.favors a low calory mixed diet, containing little meat and plenty of 
vegetables, with carbohydrate in quantity just short of producing 
glycosuria. 

Albu is the author of the most recent vegetarian system for 
diabetics. 

Carl Hanko von Noorden has occupied a position of eminence among 
diabetic specialists in the generation after Naunyn. He was trained 
under Hensen, Riegel, and Gerhardt, has directed important clinics at 
Frankfort and Vienna, and by his writings has done much to diffuse 
knowledge of the rational treatment of diabetes. The investigations 
of his large and influential school are voluminous, but belong 
mostly to the theoretical side of the subject. He long maintained the 
deficient utilization of carbohydrate in diabetes, but in the later edi- 
tions of his text-book went over to the pure overproduction h)rpothesis. 
He also supported the polyglandular doctrine, which assails the unity 
of diabetes; but, though still nominally defending it, and assigning 
great importance to the liver and the thyroid, his later writings con- 



48 CHAPTER I 

cede the essential contentions of his opponents ((2), p. 69): "But 
really these differentiations do not shake the essential unity of the 
metabolic disturbance in diabetes in the very least. I think I shall 
be voicing the opinion of all pathologists when I say that every indi- 
vidual who has a diminished tolerance for carbohydrate, either per- 
manently, or extending at least over a considerable period) and thus- 
exhibits the most important clinical symptom of diabetes, must be 
considered as a subject of pancreatic insufficiency. We need not 
always expect to find perceptible anatomical evidence, for there may be 
functional impairment where no macroscopic or microscopic patho- 
logical appearances can be discovered." Von Noorden has been un- 
fortunate in his support of false theories, but he deserves credit as the 
principal upholder against the Naunyn school of two doctrines which 
now appear to be justified by facts : first, that diabetic acidosis repre- 
sents something more than lack of carbohydrate; second, that the 
symptoms of acidosis, including the fatal termination, are due to some- 
thing more than simple acid intoxication. Von Noorden's clinical 
work has consisted chiefly in systematizing and improving the Kiilz; 
method in some details. He justifies the Kiilz treatment by the state- 
ment that he has under his care some of Kiilz's patients who have re- 
mained in good condition for seventeen years. The one distinctive 
feature introduced by von Noorden, the oat cure, was previously- 
discussed. Though he stands as the most prominent believer in the 
formation of sugar from fat, this belief has not influenced his treat- 
ment; for he "perhaps gives diabetics greater quantities of fat than- 
anybody else;" he regards fat as the anchor of their salvation; he has. 
almost never seen increase of glycosuria from it, except when digestive 
upsets occur, in which many diabetics immediately excrete more 
sugar ( (1), p. 96). Nevertheless he recognizes occasional "fat-sen- 
sitive" cases. High fat intake, greatly in excess of the requirement, 
is said to increase metabolism, like every overabxmdant diet, and' 
therewith increases the sugar excretion. But in order to produce this^ 
increase of glycosuria, the quantities of fat required are so high as to- 
be superfluous and of no practical importance in treatment. In the 
presence of severe acidosis, it is held that butter should be avoided, 
but that ordinary animal and vegetable fats cause no increase of 
ketonuria in a patient accustomed to strict diet ( (1), p. 141), and even* 



HISTORY 49 

during the transition to strict diet the administration of alkali is an 
adequate precaution (p. 293), so that fats are given freely even under 
these circumstances. In addition to alkali, von Noorden formerly- 
treated impending coma with carbohydrates, especially oatmeal, milk, 
and levulose; but recently he has found that one or two fast-days are . 
far more effective. On these days the only food is alcohol in large 
doses, up to 200 to 250 cc. cognac. As soon as the glycosuria and aci- . 
dosis are thus partially controlled, he hastens to inflict an oat cure 
( (1), p. 388). Here also the fat intake is limited, thus contradicting 
his previous contention. A large proportion of severe cases are con- 
ceded to be hopeless ; here a liberal varied diet is allowed, the glyco- 
suria being merely limited and the strength maintained ( (1), p. 371; 
(2), p. 151) and 15 to 20 gm. sodium bicarbonate and about 6 gm. 
calcium carbonate given daily for the acidosis ( (l), p. 389) . Not only 
strict diet or vegetable days, but also actual fast-days, are interposed 
in this program. ( (2), p. 93) : "There are but few diabetics who do not- 
become sugar-free on these days,^' and you will at the same time notice 
an enormous fall in the acetonuria. Fast-days, combined with bed 
rest, are excellently borne. I never find that the patient's strength 
is unduly diminished by them. An important result is regu- 
larly attained in the immediate and well-marked rise of tolerance 
which follows." Again ( (2), p. 152) : "We need have no fears that the : 
hunger day will damage seriously the general nutrition. Of course the 
body weight falls on the fast-day, but the loss is rapidly made up, and 
by this combined method we often obtain considerable increases in 
weight." Von Noorden refers to these fast-days as "metabolic Sun- 
days." The metaphor is striking and accurate, but the insufficiency 
of the metabolic rest and the attempt to build up weight in the pres- 
ence of glycosuria and acidosis are fatal to the patients and to the 
method. 

Weichselbaum and Stangl in 1901 first observed the specific "hy- 
dropic" degeneration of the islands of Langerhans. It is remarkable 
that one of the most important contributions to the morphologic 

" Remarks of this sort show the actual mildness of many cases classified by 
writers as severe. 



50 CHAPTER I 

pathology of diabetes should have met with such a complete lack of 
confirmation or credence. 

Among English writers, Williamson in 1898 published a text-Hook 
possessing permanent value by reason of the author's great experience 
and wide knowledge. Recently (2) he has made some use of a diet 
consisting only of casein and cream given in small quantities every 
two hours. He attributes the benefit to this latter device and to the 
reduction in the total quantity of food, but says: "In the most severe 
forms of diabetes with marked diacetic reaction in the urine, I do not 
at present feel justified in recommending the casein treatment." 

Cammidge ( (1), p. 297) held that with impaired fat metabolism in- 
dicated by wasting, lipemia, and acetonuria, a limitation of fat in the 
diet and its partial replacement by carbohydrate is advisable, even 
though glycosuria be increased. More recently (2) he has advocated 
a treatment resembling that of Lenne. He aptly remarks that fat 
and protein metaboHsm should be considered as well as that of sugar, 
and that the absence of any striking color reaction for protein disturb- 
ance, comparable to those for detecting sugar or diacetic acid, goes far 
to account for the neglect concerning the protein metabolism. The 
treatment consists in reduction of protein, rest in bed, and opium when 
nitrogenous equilibrium cannot be established by any other means. 
In adopting recently the fasting treatment, he has emphasized the 
study of the protein metabolism for judging the condition and progress. 

Modern France has not lived up to Bernard and Bouchardat in this 
field. Not only has it remained relatively barren of important origi- 
nal contributions, but also, outside the practice of a few specialists, 
the knowledge and management of diabetes seem to fall below the high 
general standard of French medicine. A French physician on a 
recent visit to America remarked that patients in France were less 
willing than those in other countries to adhere to restricted diet, and 
demanded a cure which would enable them to eat freely. 

Lepine has published a very large number of studies especially 
concerning blood sugar and glycolysis, but his comprehensive text- 
book alters nothing in the accepted treatment of diabetes. The 
same is true of his recent review of the therapy (2, 3). 

Fasting has been employed in diabetes not only by specialists in 



HISTORY 51 

this subject, but also by enthusiasts who advocate it as a panacea.*' 
Of these the most prominent is Guelpa of Paris. Starting from 
an incorrect observation of Dujardin-Beaumetz in typhoid fever, 
"that the more regular and rapid the patient's loss of weight, up 
to the disappearance of the pyrexia, the quicker and more favor- 
able was his course to recovery," Guelpa applied the principle first 
to infections. "I have found it an invariable rule that, in febrile 
affections, the more promptly emaciation sets in, and the more defi- 
nitely it establishes itself, the more sure and rapid is the patient's 
progress toward recovery. Conversely, when the patient fails to 
exhibit an emaciation proportional to the intensity of his pyrexia, the 
illness is always graver and of longer duration, and the convalescence 
more prolonged and more interrupted. All this, it seemed to me, 
proved, so to speak, mathematically, that disease is a state determined 
and kept up by the presence within the body of a quantity of products 
of fermentations-toxins and the debris of poisoned tissues — which the 
organism must eliminate before it can return to a condition of health." 
Having set up the theory of autointoxication as the dominant feature 
in all disease, Guelpa proposed fasting — ^generally in three-day periods 
— as the sovereign remedy. Symptoms of weakness, headache, and 
malaise during fasting, and the sensation of hunger itself, were at- 
tributed to autointoxication; food relieves the symptoms by com- 
bining with the toxin, while purgation also relieves by sweeping out 
the toxin; copious purgation — a bottle of hot Hunyadi-Jdnos water 
daily — was accordingly added to the treatment. Among the condi- 
tions for which the fasting-purgation treatment is recommended, with 
confirmatory histories of grateful patients, are gout and rheumatic 
troubles, anemia, bronchitis and asthma, herpes zoster, eczema and 
other dermatoses, various ophthalmic conditions, some gynecological 
conditions (including postpartum hemorrhage), digestive complaints, 
nervous disorders, insanity, epilepsy, drug addictions, various infec- 

'"' Some of these are outside the ranks of the medical profession. Hereward 
Carrington, in his book, "VitaKty, Fasting and Nutrition," New York, 1908, p. 
187, mentions a patient with incipient diabetes who fasted twenty days continu- 
ously, becoming free from glycosuria and remaining so for two months thereafter, 
when he was lost from observation. In the same place is a reference to a previous 
example recorded by C. C. Haskell. 



52 CHAPTER I 

tions, postoperative complications, etc. Important in the list is dia- 
betes, where alone the results have attracted widespread notice. A 
diabetic is given the usual fasting and purgation for three to five days. 
Other features of the treatment are best shown in Guelpa's own words 
((5), p. 131): 

"It is necessary to insist on the absolute necessity of repeating the cure from time 
to time, and of imposing, during the intervals, which should be carefully lengthened, 
a carefully restricted diet. As regards the latter, it is my custom to complete the 
first period of the cure (three or four days) by a week of mUk diet, the amount of 
milk taken daily not to exceed 2J pints. At the end of this week, however satis- 
factory the condition of the patient, I prescribe a second period of cure (three or 
four days) to be followed by a week or a fortnight of a regime mainly of vege- 
tables, which satisfies the patient by fiUing his stomach, but, in reality, under-feeds 
him, the object being to continue the process of forcing the organism to live par- 
tially on its reserves and to bum off its debris. The following is a menu of the 
diet I generally adopt: Breakfast, coffee or tea without milk; Lunch, clear soup, 
salad, one or two apples or pears; Dinner, as lunch. As drink, tea or other non- 
nutritive drinks ad lib. In certain special conditions I allow an ounce or so of 
bread, or a diet of cooked vegetables. I increase the amount of food after each 
repetition of the cure, taking as my guide an analysis of the urine. Since I adop- 
ted this regime, I have obtained more rapid and stable cures, without discouraging 
relapses. I wish also to draw attention to what I believe to be a deplorable error; 
namely, the doctrine that milk is very harmful in the treatment of diabetes. This 
is a mistaken view, based on a false interpretation of a single fact. It is quite true 
that diabetics kept on milk diet almost always pass an increased quantity of sugar. 
This increased excretion, is, however, only temporary. From the fact of the in- 
creased glycosuria, the conclusion has been drawn that milk is harmful in diabetes. 
The deduction is the result of a too superficial process of reasoning. It would be 
as logical to conclude that rest and warmth were harmful in the treatment of rheu- 
matic conditions, from the fact that they lead to an increased discharge of urates. 
In the case we are considering, the milk merely hastens the expulsion of sugar, 
which is injuring and impeding the tissues, relieves the hematopoietic fimction, 
and contributes to a cure, if the mistake is not made of overwhelming the blood- 
forming organs by administering a quantity of milk beyond the metabolic powers 
of the liver to deal with." 

Afterward, potatoes, bread, and other elements of a mixed ration 
are gradually added, with general admonitions against overeating. 
Acidosis is not mentioned in the records of Guelpa's early "cures." 
About 1911, something seems to have called his attention to acidosis, 
for he suddenly (7) added a new chapter to his theory of diabetes. 



HISTORY 53 

Here he announces that diabetes is the type disease of hyperacidity. 
Glycosuria is merely one of the multiple forms of defense of the organ- 
ism against acidosis caused by food pernicious in its quantity and es- 
pecially in its quality. There are several stages of the process, first 
increase of urea, later glycosuria, later acetonuria, etc., and the sixth 
and final stage is coma. The body defends itself by breaking down its 
less useful elements, notably fat; an indication is the acetonujria, which 
like the glycosuria is helpful and not harmful in the process of acidosis. 
He denounces the overfeeding in the usual treatment of diabetes, and 
denies that his method is unsuited for diabite maigre. As evidence, 
he cites the example of a patient aged sixty-five years. This man 
underwent a "cure" of five days' fasting with 40 gm. sodium sulfate 
daily. The subsequent diet of vegetables, fruits, and 60 gm. bread 
daily caused return of glycosuria, whereupon the five-day "cure" was 
repeated, followed by a similar diet. The duration of this "dis- 
toxication cure" was a month, and the result was that the patient be- 
came free from his former glycosuria, albuminuria, and joint infection. 
For threatened coma, Guelpa (7 and 11) advises copious drinks and 
enemas of sugar and weak alkaline solutions, oxygen inhalations, 
bleeding, and intravenous injections of physiological saHne or weak 
alkali. 

The Guelpa treatment has gained followers chiefly in France 
and England. Cammidge ( (1), p. 343) mentions authors reporting 
favorable results, but states that he has never been able to persuade 
any patient to undergo it. A recent favorable report is by Hume. 

Clear recognition should be accorded to Guelpa for the following 
points of merit. First: without being guided by knowledge of earlier 
undernutrition cures, and entirely from his own original and independ- 
ent thought, he devised the first plan of treating diabetes by a radical 
initial fast, longer than any previously recommended for this purpose. 
Second: these fasts were repeated a number of times, with intervening 
periods of diet very low in calories and protein and relatively rich in 
carbohydrate, and the increase toward a living ration was made 
gradually. Third : he emphasized loss of weight as a potent factor in 
the improvement, and carried the reduction of weight to a more ex- 
treme point than ventured by anyone before him, and did this even 
in patients complaining of weakness. Fourth : he was first to demon- 
strate the beneficial effect of fasting upon certain compUcations, 



54 CHAPTER I 

notably diabetic gangrene. The dietotherapy of gangrene is familiar 
in text-books, but the important observation of Guelpa was that fasting 
benefited the gangrene, instead of making it worse by weakening the 
patient. Fifth: fasting periods were employed not only whenever 
glycosuria or other symptoms appeared but also as a prophylactic 
against their return. Certain' contrary facts must also be given 
proper weight. The Guelpa treatment, in spite of its ease and sim- 
plicity, failed of acceptance at the hands of diabetic specialists and 
the immense majority of medical practitioners in all countries. The 
explanation of this fact necessarily casts discredit either upon the 
medical profession or upon this mode of treatment, and the latter 
alternative is the true one. It is frequently repeated that the cases 
treated successfully by Guelpa's method were severe, and that "the 
usual anti-diabetic regime had failed;" but the details of the unsuc- 
cessful diets are not given and the assertion cannot be accepted as cor- 
rect in a single instance. In age, the patients were almost without ex- 
ception above forty and frequently above sixty; many were obese; 
their complaints were largely the natural consequence of their mode of 
life at their time of life; on cessation of overeating and a lively purge 
they were astonished how much better they felt, and their diabetes 
was so slight that it was controlled by these simple measures with 
little or no subsequent restriction of carbohydrate. The two most 
severe cases of the series, namely that of the man described by Arnold*' 
and that of the woman described by Bardet,^ cannot be considered 

*^ Introduction to translation of Guelpa's book. 

*^ Bardet narrates that in the therapeutic clinic of Beaujon was a woman with 
diabetes of several years' duration, excreting 800 gm. sugar daily. Emaciation 
was not extreme and acutely threatening symptoms were absent. Nothing re- 
sembling the Naunyn treatment was undertaken. "She was placed for several 
weeks under the ordmary treatment of M. Albert Robin, namely alternate medi- 
cation with antipyrine and arsenic, without its being possible to reduce the 
quantity of sugar below 160 gm. After a series of this medication, the patient was 
left free from all treatment, and followed the routine diet of the diabetics of the 
service : meat 500 gm., potatoes 500 gm., green vegetables 500 gm. At the time of 
beginnmg the experiment (i.e. absolute fasting), she was passing 12 liters of urine in 
24 hours, and on the final day showed an eh'mination of 760 gm. sugar." Here is 
seen a combmation still too frequent in all countries; absence of rational treat- 
ment, dependence on drugs, the use of routine instead of individualized diets, and 
the physician's ignorance that the alleged sugar excretion on the diet stated is 
impossible. 



HISTORY 55 

examples of severe diabetes; at the utmost, they would fall in the class 
of "medium severity" according to von Noorden or Naunyn; they are 
of the type easily cleared up under the Naunyn plan of regulated diet, 
restricted protein, and intercalated fast-days, and neither of them 
remained clear Tender the Guelpa method. So far from this method 
being an improvement over the known treatment, a physician con- 
fronted with the choice of referring a patient to Guelpa or to Naunyn 
could have no possible ground for hesitation in choosing the latter. 
The Guelpa plan is applicable only to mild diabetes, and here (not- 
withstanding the quick temporary clearing of glycosuria) a permanent 
success is attained only in a longer, harder, and less certain manner 
than under the usual treatment. For diabetes of even moderate 
severity, the attempt to fast, purge, and undernourish a patient until 
he is able to tolerate carbohydrate-rich diet is inevitably disastrous. 
In undertaking to apply the mode of treatment described in the pres- 
ent monograph, the most common difl&culty and mistake of inexperi- 
enced physicians has been to fast the patient till free from glycosuria, 
then to give a diet permitting its return, then to fast, then to proceed 
with improper diet, so that weight and strength are lost while tolerance 
is injured instead of improved, and the end in any severe case will be 
fatal. In the one young patient of his series, a youth of sixteen years, 
with actually severe diabetes, Guelpa ( (5), p. 112) achieved sugar- 
freedom after fifteen days, but relapse followed because the patient 
finally found the program unendurable. There may be justifiable 
surprise that Guelpa describes only successes; in his half dozen or less 
of partially successful cases the blame for mishaps is placed entirely 
upon the patients. Inasmuch as common knowledge and Guelpa's own 
experience ( (1), p. 506) make it clear that purgation does not prevent 
acidosis during fasting, it would be remarkable if so many diabetics 
should be treated without encountering some of those severe cases of 
long standing who go into fatal acidosis on fasting. There is still more 
noteworthy absence of a record of any young patient with impending 
coma who was cleared up and kept clear of both glycosuria and aci- 
dosis. It is improbable that Guelpa avoided such cases altogether; 
it is certain that his treatment must fail in the vast majority of them; 
and his record of success limited to mild cases constitutes sufficient 
evidence of his failure in more severe cases, even of the grade that can 



56 CHAPTER I 

be managed successfully under the Naunyn plan. On the one hand, 
Guelpa should receive due credit for boldness, enthusia,sm, originality, 
and some new observations growing out of a new clinical procedure. 
On the other hand, it cannot be maintained that Guelpa devised a 
good treatment for diabetes. The lesson of his work cannot be over- 
looked; but the information and encouragement derivable from his 

'long fasts in mild cases are less than from the shorter fasts of Naunyn 
and von Noorden in severe cases, so that the proposed treatment of 
severe cases by fasting is a development of the Naunyn method rather 
than of the Guelpa method. 

America has not been prolific of diabetic text-books. A notable 
early example is that of Tyson, the frontispiece of which shows the 
intraocular picture by which diabetic lipemia can be diagnosed. 
■ The &st great contribution of this country to this subject was 
Opie's hypothesis that diabetes is due to alterations in the islands of 
Langerhans, on the basis of findings of hyaline, fibrous, and other 
destructive changes in the islands in a series of cases where the acinar 

■ tissue was relatively little affected. 

Mandel and Lusk demonstrated the dextrose-nitrogen ratio of the 
phloridzinized dog in a human diabetic, and drew attention to the 
prognostic value of this ratio. Lusk's "Science of Nutrition" treats 
a subject of such dominant importance for intelligent dietotherapy 
that it may be placed in the highest rank among text-books of diabetes. 
The most extensive investigation of the respiratory metabolism in 
diabetes is that of Benedict and Joslin. 

Hodgson treated over 1100 patients in the twenty years preceding 
1911. He worked out a plan of treatment without drugs, using a 
mildly alkaline mineral water freely. He held that patients "should be 

kept mentally indolent and physically active One other 

essential must be made' plain to the diabetic, and that is the quantity of 

food eaten is just as important as the kind of food It is a 

fact that many mild cases of diabetes will show a diminution of sugar 
almost to the vanishing point when the patient is merely compelled 
to eat a very moderate ordinary diet. That is to say an antidiabetic 
diet is not always necessary to reduce the glycosuria; a reduction in the 
amount of ordinary food will sometimes accomplish the same end. 

' . . . . Again it should be stated that the quantity of all food, even 



HISTORY 57 

if it is carbohydrate-free, must be greatly restricted. The number of 
calories that the body ordinarily requires is no safe criterion for the 
amount of food that should be given a diabetic. It is not the quantity 
of food that should be metabolized, but the quantity that can be me- 
taboUzed that should determine the amount given to the patient. All 
in excess of the quantity that the patient can actually use burdens the 
already overtaxed excretory organs and retards improvement." In cases 
severe enough that sugar did not disappear after two weeks of strict 
diet, the patient was put to bed and allowed one raw egg and two 
ounces of olive oil three or four times a day. If diacetic acid appeared, 
the oil was diminished and some carbohydrate added. Hodgson's 
statistics show a high percentage of favorable results in cases not too 
severe in t}T)e. 

Foster's manual (1915) is not only an excellent brief presentation of 
the Naunyn system, but distinctly goes beyond this in the more radical 
employment of undernutrition, with correspondingly better results. 
He lays down the wise rule (p. 165) in contradiction to some European 
authorities, that it is not safe to disregard diabetes even in advanced 
life. By the use of repeated fast-days, vegetable days, and restricted 
diet he achieves freedom from glycosuria in cases of the type given up 
as hopeless by many writers. The procedure in such cases is slow, 
and the control transitory (p. 216). "By the enforcement of rest in 
bed and a stringent diet the urine can be freed of sugar in the vast 
majority of cases. With early cases the result is often effected within 
a few days; when the disease is advanced and there is a complicating 

severe acidosis, months may be necessary These are the 

most discouraging cases, as they never approach a semblance of health. 
. . . . At once on beiiig released from incessant control, there is 
an inevitable transgression beyond the path of safety in diet and exer- 
cise. . . . . With severe cases of diabetes coma develops finally 
in spite of the best endeavors." 

Mosenthal applied the hospital class system to the care of diabetics.** 
The method is particularly adapted to a disease in which instruction 
of patients is so essential as in diabetes, and it is the most effective 
practical measure in the organization of a clinic, both for the care of 

^' Cf . Joslin ( (4), pp. 327 and 409) . 



58 CHAPTER I 

ambulant cases and for guarding against relapse in patients after dis- 
charge from hospital. More widespread and effective social service 
along these lines offers one of the most important means of diminishing 
the death rate from diabetes. 

Woodyatt (1) was one of the very few who in 1909 held clearly to 
the conception of diabetes as a deficiency of the internal function of the 
pancreas.'** Woodyatt (3) has recently suggested that the weakness 
of the pancreatic function here concerned may not always be an in- 
herited or constitutional defect in the Naunyn sense, but may some- 
times be acquired, especially through infections which selectively 
injure either the pancreas or the nervous mechanism cohtroUing it. 

^ "Diabetes mellitus is a disease in which the body has in part lost its ability 
to utilize sugars. Sugar arrives at the point where it should burn, but fails to do 
so, and accumulating in the blood creates an hyperglycemia. Disregarding acces- 
sory factors, which may play a part, we can say that ultimately the failure of sugar 
combustion in diabetes mellitus depends upon lack of 'a something derived from 
the pancreas.' The pancreas, like other glands, is capable of being stimulated intO' 
a state of fatigue. It may be conceived that excess of sugar in the blood of healthy 
individuals acts directly or indirectly (e.g. through nerves) as a stimulus to the 
pancreas, as a result of which more internal secretion is set free and the excess of 
sugar thereby automatically taken care of. This removed, the stimulating in- 
fluence ceases and the pancreas rests. In diabetes it may be assumed that the 
pancreas is functionally weak. A small excess of sugar in the blood, let us say,. 
calls for a response from the pancreas, and as in health the excess may be removed. 
Sooner or later, perhaps as a result of some dietary excess, or of some shock to the 
nervous system which results in an outgush of sugar from the glycogen depots of 
the liver, an unusual hyperglycemia occurs. This calls for a strong pancreatic 
response, more than the functionally weak gland can give, and some excess of 
sugar remains unutihzed in the blood. If hyperglycemia persists for any appreci- 
able time the continuous pancreatic stimulation thereby engendered results in 
glandular fatigue. Less and less secretion is elaborated, less and less sugar utilized, 
the hyperglycemia grows progressively worse and a vicious circle becomes es- 
tablished. The condition of the pancreas then corresponds to that of a heart with 
broken compensation, and as the treatment for such a cardiac condition is rest, so 
in diabetes rest is needed for the pancreas. To secure this we must control the 
stimulating hyperglycemia, which means primarily the withdrawal of carbohy- 
drates from the diet, secondarily reduction in the amount of protein, until absence 
of glycosuria tells us that the blood sugar percentage is approximately normal. 
After prolonged rest of this sort a return of the pancreatic function to its previous- 
state is frequently spoken of as an increased body 'tolerance for sugar.' 

Such restoration of sugar-burning capacity, such increase in 'tolerance' is the- 



HISTORY 59 

Raulston and Woodyatt in 1914 described a case of diabetes, for which 
fasting had been used.^* Woodyatt (2) said at a symposium on dia- 
betes before the Association of American Physicians in 1915: "For 
eight years at the Presbyterian Hospital we have regularly used starva- 
tion in the treatment of diabetes, following principles with which I 
became acquainted in the clinic of Muller in Munich. We have fasted 
patients for the purpose of desugarization for periods of one, two, 
three, and in one case five days, and have kept patients for prolonged 
' periods in semistarvation. There can be no doubt of its value in cer- 
tain phases of treatment. As to its safety, I have seen two deaths 
apparently from spread of infection immediately following a period 
of fasting." 

first aim of diabetic therapy. There are cases in which the ability of the 
body to utilize carbohydrate has sunk so low that as a result certain secondary 
changes in the fat metabolism have supervened. These changes are mainly re- 
sponsible for the condition spoken of as acidosis. In health and in diabetes with- 
drawal of carbohydrate from the diet frequently causes the appearance of a pre- 
viously absent acidosis or an increase in the severity of an already existing one. 
These aggravations are temporary. Still in such cases as already have a danger- 
ously large amount of the acetone bodies in the blood no increase at all is per- 
missible. In these cases, and only in these cases, should one refrain from an at- 
tempt to improve tolerance. Just where to draw the line is a matter for individ- 
ual judgment. Where means are at hand for accurate quantitative measurements 
of the daily excretion of acetone bodies one may be justified in closely approaching 
the danger point. When these means are not available a more respectful margin 
of safety must be maintained." 

*^ "We made a transfusion of blood into the veins of a patient suflfering from 
diabetes mellitus, one for whom all known expedients had been exhausted and who 

was approaching the end The patient, a man, aged thirty-four, had 

first shownsymptomsofdiabetessixyearspreviously For two years the 

symptoms had been severe, and for eighteen months prior to the transfusion he 
had been constantly under observation in the Presbyterian Hospital, Chicago, 
where on numerous occasions his metabolism had been studied for prolonged 
periods. Prior to entering he had twice become unconscious with what had been 
diagnosed as diabetic coma, and on several occasions afterward coma was 
averted only by the enforcement of complete bodily rest and the use of maximum 
doses of alkali and wine. He became fully educated with regard to the require- 
ments of a metabolism study and voluntarily cooperated in a highly intelligent 
way. He knew that the expectancy of life was very limited and solicited the 
trying of any new line that might even temporarily mitigate his condition or 



60 CHAPTER I 

In the same discussion, Billings (1) spoke to similar effect.*^ Re- 
cently Billings (2) has written, "In the service of the Editor in the 
Presbyterian Hospital, Chicago, in collaboration with Dr. R. T. 
Woodyatt, the treatment of diabetes by a preliminary absolute fasting 
period, until the urine is sugar-free, has been followed for nine years. 
We have fasted patients for as long as eight days. The patient is 
encouraged to drink water freely. Acidosis usually diminishes 
rapidly. One may give whisky or sour wine during the fasting period. 
Soda bicarbonate may also be used in persistent acidosis. All that is ' 
said by Allen and Joslin concerning the treatment we can afSrm." 

I^o clear up possible misunderstandings, the following may be 
remarked: 

(1) Friedrich Miiller has published nothing in regard to the principles attributed 
to him. On the contrary, Staubli published (1908) the records of one clinic patient 
and two private patients of Friedrich Miiller, showing that they were treated by 
the Naunyn method, and though the treatment continued for a number 
of months and the cases were not extremely severe, they continually showed marked 
glycosuria and ketonuria and were dismissed with these still present. Further- 
delay the end. On several occasions his glucose to nitrogen ratio closely approx- 
imated 3.65 : 1 on a diet aggregating 2,500 calories (due allowance having been 
made for ingested carbohydrate). Nevertheless his urine coiild always be 
rendered sugar-free by fasting, and on semistaryation (the Falta-Lusk quotient) 
could be reduced from 100 or thereabouts to the neighborhood of 50, as it was on 
the diet used at the time of transfusion. During the time of observation the 
patient remaiaed quietly in bed. Diet. — For two weeks prior to the transfusion 
and for five days afterward the diet consisted of 800 cc. of 16 per cent cream, three 
eggs (150 gm.), and water, clear tea or coffee to make the total volume of fluid two 
liters daily." The patient died shortly after this time. 

** "I am surprised to hear it said that the method of starvation of diabeticpatients 
is new. We have used that method in Chicago for a number of years and patients 
have been fasted for as long as eight days. The adoption of the method there was 
due to the work of Woodyatt. A point to be remembered is that the study of 
patients at rest in a hospital is only part of the problem; it is necessary to study 
them after exercise, after return to ordinary mode of life. For years, I have taught 
patients how to examine their own urine. While it may be harmful to give fats in 
general in diabetes, butter fat is not harmful. Diabetics may take butter fat or 
bacon fat and may do so for years. Whatever may be said, it is impossible ever 
really to control diabetic patients; they will do as they please as soon as they get 
beyond the observation of the doctor." 



HISTORY 61 

more, personal letters recently received show that Friedrich Miiller has no knowl- 
edge of the proposed treatment, and considers it theoretically inadvisable because 
of the supposed danger of acidosis.*' Such an attitude on the part of one so 
widely informed concerning diabetes and so familiar with the Naunyn method, 
affords some evidence of the newness of the proposed treatment and the principles 
underlying it. 

(2) Though Woodyatt states (1915) that an initial fast has been used for eight 
years, and Billings (1916) that it has been used for nine years, the above quoted 
therapeutic program of Woodyatt (1) makes no mention of the use of such a 
method in 1909; on the contrary, it is there advised, in harmony with Naunyn, 
that in cases with very dangerous acidosis one should "refrain from an attempt to 
improve tolerance." No description of the new method has since been pubHshed 
by either of these authors. 

(3) The paper of Raulston and Woodyatt makes incidental reference to fasting 
and semistarvation. It seems evident that the plan of fasting used and referred to 
by these authors resembled that of von Noorden, the only difference being that the 
periods were sometimes longer; the effect is a temporary cessation of glycosuria 

*' One letter was addressed to Professor Graham Lusk, and another to one of the 
present authors. Liberty is taken to quote from the latter, under date of August 
1,1915. 

"Die Frage einer kalorisch armen Ernahrung bei Diabetes ist vor einigen Jahren 
in der deutschen Literatur durch Schlesinger erortert worden, und er hat gezeigt, 
dass Diabetiker haufig bei einer an kalorieri auffallend armen Nahrung sich erhal- 
ten. Ein Nutzen fiir die Kranken wird aus dieser Arbeit nicht erkenntlich. Dann 
hat Weintraud vor Jahren in seinen aus der Naunynschen Klinik kommenden in 
der Bibliotheka medica erschienenen Arbeit auf die Bedeutung einer zeitweiligen 
Unteremahrung hingewiesen, und Sie finden diese Gesichtspunkte in dem Buch von 
Naunyn iiber Diabetes ausfiihrlich dargelegt. Wir verwenden in Deutschland 
zeitweiUge Unteremahrung, sogenannte Hungertage, ganz gewohnHch zur Re- 
duktion des Zuckers, und scheuen uns nicht das Korpergewicht dadiirch zu re- 
duzieren. Freilich gelingt es nur selten durch solche Hungertage die Acidosis zu 
vermindern, da ja der Hunger an sich auch bei gesunden Menschen ausgesprochene 
Acidosis zu erzeugen pflegt. Jeder Hungerzustand fiihrt zu Verbrennung von 
Korperfett imd erzeugt daher bei Mangel an Glykogen eine Acidosis. Bei Dia- 
betes, wo der Glykogenvorrat ohnedies reduziert ist, und wo die Zuckerverbren- 
nung haufig schwer geschadigt ist, tritt die Hungeracidosis gewohnlich noch 
starker hervor, und erschwert die Behandlung durch Unteremahrung. Eine 
generelle Verordnung der Unterernahrang bei Diabetes dtirfte schon aus dem 
Grunde nicht ganz ohne Bedenken sein, well die Diabetiker unter einander so un- 
geheuere Verschiedenheiten zeigen, dass man sich hiiten muss alle Falle nach der- 
selben Regel zu behandeln. Das letzte Wort in dieser Frage hat jedenfalls nur die 
Erfahrung, nicht aber die Theorie." 



62 CHAPTER I 

and diminution of ketonuria at the price of a certain amount of weiglit and nutri- 
tion, but the diet after the fast permits a quick return of the symptoms. It is 
expressly stated that in the semistarvation periods the Falta-Lusk quotient^* was 
still about 50, which means serious glycosuria; and it is obvious that marked 
ketonuria was constantly present. Billings' opinion concerning fat, and the high 
fat diet used by Raulston and Woodyatt, suffice to explain such a result, for without 
fat restriction these patients cannot be kept free from such symptoms. 

Misunderstanding of the incomplete description of the method in the brief pre- 
liminary communications was evidently responsible for the early criticisms of this 
character. Aside from the fundamentally new principle of total caloric regulation, 
it has been necessary to develop many practical details. The discussion of the 
resulting system has in general remained free from questions of priority. 

Joslin has had the largest experience in the treatment of severe dia- 
betes in this country, and has published the latest as well as the most 
advanced and authoritative text-book. No other American clinician 
has followed the scientific study of diabetes so long and intensely. 
His careful records cover approximately 1000 diabetic patients treated 
during the past eighteen years, and are particularly valuable because 
the great majority of the cases have been accurately followed up to 
death or to the present time. His definition is one which when gener- 
ally adopted will tend to lower the death rate from diabetes and its 
complications. "My rule in the treatment of diabetes is to consider 
any patient to have diabetes mellitus and treat him as such, until the 
contrary is proven, who has sugar in the urine demonstrable by any of 
the common tests. This method of procedure is safer for the patient 
than to make use of the term glycosuria, which begets indifference." 
He has laid emphasis upon the necessity of keeping patients supplied 
with sufficient quantities of fluid and salts. He has been closely in 
touch with the development of the fasting treatment from the outset. 
He was informed in advance concerning the first clinical results, and 
has treated a greater number of severe cases of diabetes by this method 
than any other individual. The rapid general adoption of the method 
has been largely due to his example and influence, and in his various 
publications he has formulated a detailed program which many prac- 
titioners have followed. The reversal of conditions is shown by the 
fact that whereas fat was formerly the only food not restricted, 

«Cf.Lusk(2). 



HISTORY 63 

Joslin now begins treatment by withdrawing only fat. His statistics 
-support the belief that the life of diabetic patients is lengthened by the 
new method, and in his judgment they enjoy also better strength and 
'Comfort. References to and comparison with Joslin's results afford 
valuable information on the questions discussed in the ensuing chap- 
ters, and certain topics can be here omitted altogether because of the 
manner in which he has handled them on the basis of a wider experience. 

One of the present writers*' previously published work which seemed 
to promise the possibility of investigating diabetic therapy by animal 
experiments. The conception underlying the subsequent research at 
this Institute had a threefold origin. One lay in considerations from 
the literature as above mentioned, and also the reports of cessation of 
'diabetes in various forms of cachexia {loc. cit., p. 800 ff.). The second 
was found in certain of the preceding observations; viz., that in dogs 
with severe diabetes not too far advanced, glycosuria ceased and tiie 
diabetes seemed more or less improved on fasting alone {loc. cit., p. 480, 
Dog 64), or together with ligation of the pancreatic duct (Chapter 
XXII). The latter experiments were repeated and the role of im- 
paired food absorption and undernutrition demonstrated by Homans. 
The third suggestion was furnished by Joslin,^" who in a conversation 
-called attention to his observations that though infections are gener- 
;ally so serious in diabetes, tuberculosis with rapid emaciation had 
•seemed sometimes, notably in one very carefully studied case, to be 
.accompanied by diminution of both glycosuria and acidosis. 

On these various grounds, animal experiments were begun with a 
view to the possibility that diabetes is a disorder of the total metabo- 
lism and not of carbohydrate utihzation alone, that the entire diet and 
maintenance of the entire body mass constitute a load upon the inter- 
nal function of the pancreas, and that accordingly in the treatment of 
•diabetes increase of diet and of body weight increases the strain upon 
this function, and reduction of the total diet and weight relieves this 
;;strain more effectively and permanently than restriction of carbo- 
hydrate alone. A series of animal experiments seemed to support this 

« Allen (1). 

^ Cf. Benedict and Joslin, p. 55, Case R; also Joslin, Treatment of Diabetes 
:Mellitus, 2nd edition, 1917, p. 409. 



64 CHAPTER I 

conception, which was then applied to the treatment of diabetic 
patients. Some of the results have been outlined in preliminary 
communications, which, however, have not been sufficient to convey 
an accurate knowledge of the details, and results have varied somewhat 
with the different appHcations of the method in different hands. 

Among authors who have reported favorable experiences are: in 
America, Barker, Bookman, Christian, Friedenwald and Limbaugh, 
Greeley, Halsey, Hamburger, Heffron, Heyn and Hawley, Hill and 
Eckman, Hill and Sherrick, Jeans, Jones, Lemann, Levy, Lovewell, 
Marshall, Martin and Mason, McNabb, Moses, Paley, Potter, Rob- 
bins, Stengel and collaborators, Strouse, and Wilhams; in England, 
Cammidge, Fenwick, Leyton, Spriggs, and speakers discussing their 
papers; in Ireland, Nesbitt; in India, Waters. Its adoption by 
speciahsts and institutions, and by a still greater number of general 
practitioners, has furnished gratifying evidence not only of its theo- 
retical soundness but also of its feasibihty for successful practical 
application under the many varied conditions of medical work and 
environment. Geyelin and DuBois, and Jonas and Pepper, have 
demonstrated the possibility of beneficial results in the most intense 
uncomplicated cases ever described in the literature of diabetes. 

Aside from any benefits inherent in the treatment itself, it has 
apparently served to stimulate interest in diabetes among members of 
the medical profession, and to promote the understanding and employ- 
ment of rational dietetic management of this disorder, than which 
none has been more poorly understood or treated. Such knowledge 
and confidence concerning the rational therapy will diminish the use 
of the worthless or harmful remedies which appeal to ignorance or 
despair. The history of the development of the scientific treatment, 
and of some among the many contributors to it, may;fittingly be closed 
with a quotation from Naunyn ( (5) , p. 452) . "The interest in novelty 
may be granted also to physicians, and the lack of prejudice with 
which we accept for trial all things, even the strangest and from the 
worst source, may — so far as one may believe in it — ^be praised; but 
every physician must beware of undertaking such special treatments 
or of recommending them, without ascertaining their relation to what 
science has estabHshed and teaches concerning the therapy of our 
disease. If this is not possible for him, then the employment of them 



HISTORY 65 

is not permissible. The therapy of diabetes has been well founded by 
painstaking labor highly fruitful in all directions; we may be proud of 
that which has been achieved and attained here. The physician who 
here frivolously abandons the scientific basis must, if he wishes to be 
deemed honorable, submit to the accusation of ignorance." 

BIBLIOGRAPHY. 

Allen, F. M., (1) Glycosuria and Diabetes, Harvard University Press, Cam- 
bridge, 1913. 

(2) Studies Concerning Diabetes, /. Am. Med. Assn., 1914, Ixiii, 939. 

(3) The Treatment of Diabetes, Boston Med. and Surg. J., 1915, clxxii, 

241-247. 

(4) Prolonged Fasting in. Diabetes, Tr. Assn. Am. Phys., 1915, xxx, 323- 

329; Am. J. Med. Sc, 1915, cl, 480-485. 

(5) Metabolic Studies in Diabetes, N. Y. State J. Med., 1915, xv, 330-333. 

(6) Note Concerning Exercise in the Treatment of Severe Diabetes, Boston 

Med. and Surg. J., 1915, clxxiii, 743-744. 

(7) Investigative and Scientific Phases of the Diabetic Question, J. Am. 

Med. Assn., 1916, kvi, 1525-1532. 

(8) Some Clinical Phases of Diabetes, Tr. College Phys. Philadelphia, 1916, 

xxxviii, 249-254. 

(9) The R61e of Fat in Diabetes, The Hai-iiey Lectures, 1916-17, xii, 42- 

n\;Am. J. Med. Sc, 1917, chii, 313-371. 
(10) The Present Outlook of Diabetic Treatment, Tr, Assn. Am. Phys., 

1917, xxxii, 138-148. 
Allen, F. M., and Du Bois, E. F., Metabolism and Treatment in Diabetes, 

Arch. Int. Med., 1916, xvii, 1010-1059. 
Baedet, G., Diete absolue et alimentation restreinte dans le diab^te. Bull. gin. 

thSrap., 1909, clvii, 308-315. 
Barker, L. F., Diabetes Mellitus, Monographic Medicine, 1916, iv, 816-839. 
Batjmel, L. (1) Pancreas et diabete, Montpellier Mid., 1881, xlvii, 406-413; 

1882, xlviii 31-40, 442-462. 
(2) Nouvelle theorie pancreatique du diabete Sucre, Ihid., 1889, xiii, 314- 

353. Ref. by Lepine and Sauerbeck. 
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Institution of Washington, 1910; A Study of Metabolism in Severe 

Diabetes, Ihid., 1912. 
Bernard, C, (1) De I'origine du sucre dans Teconomie animale. Arch. gin. 

mid., 1848, xviii, 303-319. 

(2) Lefons sur la physiologic et la pathologie du systSme nerveux, Paris 

1858. 

(3) Lefons sur la diabete et la glycogenese animale, Paris, 1877. 
Billings, F., (1) Discussion, Tr. Assn. Am. Phys., 1915, sxx, 338. 

(2) Diabetes Mellitus, The Practical Medicine Series, 1916, i, 328. 



66 CHAPTER I 

BiOT, (1) Sur un caractere optique k I'aide duquel on reconnatt immediatement 
les sues vegetaux qui peuvent donner du sucre analogue au sucre 
de Cannes, et ceux qui ne peuvent donner que du sucre semblable 
au Sucre de raisin, Ann. chim. et phys., 1833, lii, 58-72. 
(2) Ueber Bestimmung der BeschaSenheit und Quantitat des Zuckers in 
Saften durch ein optisches Kennzeichen, Pharm. Centr., 1833, iv, 
353-356. 

Blum, L., (1) Ueber Weizenmehlkuren bei Diabetes mellitus, MUnch. med. 
Woch., 1911, Iviii, 1433-1439. 

(2) Die Diat bei Diabetes gravis, Med. Klin., 1913, ix, 702-705. 

(3) Les hydrates de carbone dans le traitement du diabete sucre, Semaine 

mid., 1911, xxxi, 313-318. 
Bookman, A., The Allen Treatment in Diabetes Mellitus, N. Y. Med. J., 1915, 

cii, 1240-1242. 
Bose, C. L., Discussion on Diabetes in the Tropics, Brit. Med. J., 1907, ii, 1053- 

1054. 
BoucHAKD, C, (1) Lefons sur les maladies par ralentissement de la nutrition, 

Paris, 1890. 
(2) Troubles prealables de la nutrition, traite de pathologic gen6rale, 

Paris, 1900, iii, 179-415. 
BoucHARDAT, A., (1) Du diabete sucre ou glucosurie; son traitement hygienique, 

Paris, 1851. 
(2) De la glycosurie ou diabete sucre, Paris, 1875. 
Cammidge, p. J., (1) Glycosuria and Allied Conditions, London, 1913. 

(2) The Nitrogen Balance in Diabetes MeUitus and Its Importance in 

Treatment, Lancet, 1915, ii, 1187-1189. 

(3) The New Dietetic Treatment of Diabetes, Ibid., 1917, ii, 522-527. 

(4) The New Dietetic Treatment of Diabetes, Brit. Med. J., 1917, i, 503-505. 

(5) The Importance of Regulating the Fat-Intake in Diabetes Mellitus, 

Ibid., 1918, i, 393-395. 
Camplin, J. M., On Diabetes, and Its Successful Treatment, London, 1858. 
Cantani, A., (1) Der Diabetes mellitus, translation by Siegfried Hahn, Berlin, 1877. 
(2) Le diabete sucre et son traitement dietetique, translation by H. Charvet, 
Paris, 1878. 
Cawley, T., A singular Case of Diabetes, consisting entirely in the Quality of 
the Urine: with an Inquiry into the different Theories of that Dis- 
ease, London Med. J., 1788, ix, 286-308. 
Chevallier, a., Sur I'urine des diab6tiques, J. chim. mSd., pharm., et toxical., 

1829, V, 7-12. Ref. by Griesinger. 
Chevreul, (1) Note sur le sucre de diabetes. Bull. Soc. philomatique, 1815, 
148-149. 
(2) Note sur le sucre de diabetes, Ann. chim. et phys., 1815, xcix, 319-320 
Ref. by Lepine. 



HISTORY 67 

Christian, H. A., The Starvation Method versus Gradual Carbohydrate Re- 
duction as a Time Saver in the Treatment of Diabetes, Boston Med. 

and Surg. J., 1915, ckxii, 929-933. 
Christie, T., Notes on Diabetes Mellitus, as It Occurs in Ceylon, Edinburgh 

Med. and Surg. J., 1811, vii, 285-299. 
CsONKA, F. A., The Fate of Ingested Starch in Phlorhizin Diabetes, J. Biol. 

Chew.., 1916, xxvi, 327-329. 
CuLLEN, G. E., Studies of Acidosis. III. The Electrometric Titration of Plasma 

as a Measure of Its Alkaline Reserve, J. Biol. Chem., 1917, xxx, 

369-388. 
CuLLEN, W., (1) First Lines on the Practice of Physic, Edinburgh, 1st edition, 

1776-1784. 
(2) Synopsis Nosologiae Methodicae, Edinburgh, 1769. Ref. in texts. 
DiNGUizLi, Diabete sucre et son traitement sans regime, d'apres les auteurs 

arabes anciens. Bull. Acad, mid., 1913, Ixx, 629-635. (Report by A. 

Robin.) 
DoBSON, M., Experiments and Observations on the Urine in Diabetes, Medical 

Observations and Inquiries by a Society of Physicians in London, 

1776, V, 298. 
DoNKiN, A. S., (1) On the Relation between Diabetes and Food and Its Appli- 
cation to the Treatment of the Disease, London, 1875. 
(2) The Skim-Milk Treatment of Diabetes and Bright's Disease, London, 

1871. 
VON During, A., Ursache und Heilung des Diabetes mellitus, Hanover, 2nd 

edition, 1875. Ursache und Heilung der Zuckerkrankheit, Hanover, 

5th edition, 1905. 
DuPTJYTREN and Thenard, Memoire sur le diabetes sucre, /. med., chir., 

pharm., etc., 1806, xii, 77-111; Bull. Faculte Med. Paris, 1812, 

i (1806), 37-42. 
Ebstein, W., (1) Uber Driisenepithelnekrosen beim Diabetes mellitus mit be- 

sonderer Beriicksichtigung des diabetischen Coma, Deutsch. Arch. 

klin. Med., 1881, xxviii, 143-242. 

(2) Die Zuckerharnruhr, ihre Theorie and Praxis, Wiesbaden, 1887. 

(3) Ueber die Lebensweise der Zuckerkranken, Wiesbaden, 2nd edition, 

1898. 

(4) Beitrag zum respiratorischen Gaswechsel bei der Zuckerkrankheit, 

Deutsch. med. Woch., 1898, xxiv, 101-102. 
Falta, W., (1) Die Therapie des Diabetes mellitus, Ergebn. inn. Med. u. Kinderh., 

1908, ii, 74-141. 
(2) Ueber die gemischte Amylazeenkur bei Diabetes mellitus, Milnch. 

med. Woch., 1914, Ixi, 1218-1220. 
Faroes, F., L'assimilation du sucre de lait chez le diabetique; une therapeutique 

rationelle du diabete, Gaz. hebd. sc. mid. Bo^(ieoMx, 1915, xxxvi, 33-37. 



68 CHAPTER I 

Feeling, H., Ueber die quantitative Bestimmung von Zucker und Starkemehl 
mittelst Kupfervitriol, Ann. Chem. et Pharm., 1849, Ixxii, 106-113; 
Chem. Pharm. Centr., 1850, xxi, 244-246. 

Fenwick, p. C. C, Notes on the Starvation Treatment of a Young Diabetic, 
Lancet, 1917, i, 299. 

FiTZ, R., (1) Acetone Bodies in the Blood in Diabetes, Tr. Assn. Am. Phys., 
1917, xxxix, 155-158. 
(2) Observations on Kidney Function in Diabetes Mellitus, Arch. Int. 
Med., 1917, xx; 809-827. 

FiTZ, R., and Van Slyke, D. D., Studies of Acidosis. IV, The Relationship be- 
tween Alkaline Reserve and Acid Excretion, /. Biol. Chem., 1917, 
XXX, 389-400. , ■ 

Foster, N. B., Diabetes Mellitus, Philadelphia and London, 1915. 

VON Freeichs, F. T., (1) R. Wagner's Handworterbuch der Physiol., 1846, iii, 
'part 1), 803. 

(2) Ueber den plotzlichen Tod und fiber das Coma bei Diabetes (dia- 

betische Intoxication), Z. klin. Med., 1883, vi, 1-53. 

(3) Ueber den Diabetes, Berlin, 1884. 

Friedenwald, J., and Limbaugh, L., The Allen Treatment of Diabetes, Inter- 
state Med. J., 1916, xxiii, 73-79. 

Gerhaedt, C, Zur Aetiologie und Therapie des ninden Magetageschwlirs, Wien. 
med. Presse, 1868, vi, 1. 

Geyelin, H. R., and Du Bois, E. F., A Case of Diabetes of Maximum Severity 
with Marked Improvement. A Study of Blood, Urine and Respira- 
tory Metabolism, J. Am. Med. Assn., 1916, Ixvi, 1532. 

Greeley, H. P., Diabetes Mellitus. Broader Aspects of Treatment and Re- 
sults, J. Am. Med. Assn., 1917, Ixviii, 1685-1689. 

Gregory, G., Elements of the Theory and Practice of Physic, London^ 2nd 
edition, 1825. 

Griesinger, W., Studien iiber Diabetes, Arch, physiol. Heilk., 1859, iii, 1-75. 

Guelpa, G., (1) Cure du diabete (and Discussion), Bull. gin. thSrap., 1909, 
clvii, 91-105, 494-508; Nouvelle contribution a I'dtude da la purga- 
tion. Ibid., 770-789. 

(2) Sur la purgation. Ibid., 1909, clviii, 182-189, 213-221. 

(3) R6sultats eloignes de 19 cas de diabete trait^s par la m6thode de desin- 

toxication, Ibid., 1910, clix, 213-221. 

(4) Autointoxication et disintoxication, Paris, 1910. 

(5) Autointoxication and Disintoxication, translation by F. S. Arnold, New 

York, 1912. 

(6) Starvation and Purgation in the Relief of Disease, Brit. Med. J., 1910, 

ii, 1050-1051. 

(7) Interpr6tation des manifestations diab6tiques, traitement du diabete, 

Bull. gSn. thirap., 1911, clxii, 925-931. 

(8) La goutte, son traitement, Ibid., 1912, clxiv, 709-716. 



HISTORY 69 

GuELPA, G., (9) Hygiene des chevaux et regime vegetarian. La goutte, (review 
in Lyon Mid., 1913, cxxi, 1082-1084). 

(10) Proc. Internal. Cong. Med., 1913, vi, 392, (brief remark). 

(11) Desintoxication de I'organisme, Paris, 1913, (review in Lyon MSd., 

1913, cxx, 1204-1206). 
GuELPA, G., and Makie, A., La lutte contre I'epilepsie par la disintoxication et 

par la reeducation alimentaire. Bull. gin. ihhrap., 1910, clx, 616-624. 
Hallervorden, E., Ueber Ausscheidung von Ammoniak im Urin bei patholo- 

gischen Zustanden, Arch. exp. Path. u. Pharm., 1880, xii, 237-275. 
Halsey, J. T., (1) The Allen Treatment of Diabetes, New Orleans Med. and 

Surg. J., 1915-16, Ixviii, 501-509. 
(2) The Dietetic Treatment of Surgical Diabetes, South Texas Med. Rec, 

1916, X, 10-13. 
Hambitrger, W. W., The Allen Treatment of Diabetes, Med. Clinics Chicago, 

1916, i, 1051-1075. 
Harley, G., Diabetes, Its Various Forms and Different Treatments, London, 

1866. 
Heffron, J. L., The New Conception of Diabetes and Its Treatment, iV. Y. State 

J. Med., 1916, xvi, 69-71. 
Heyn, L. G., and Hawley, P. R., The Allen Treatment of Diabetes Mellitus, 

Lancet-Clinic, 1915, cxiv, 42-45. 
Hill, L. W., and Eckman, R. S., The Starvation Treatment of Diabetes. With 

a Series of Graduated Diets, Boston, 1915, 1916, 1917. 
Hill, L. W., and Sherrick, J. L., Report on the Allen Treatment of Diabetes, 

Boston Med. and Surg. J., 1915, clxxii, 696-700. 
HiRSCH, A., Handbook of Geographical and Historical Pathology, translation 

by Charles Creighton, New Sydenham Society, London, 1885, ii. 
Hirschfeld, F., Ueber eine neue klinische Form des Diabetes, Z. kUn. Med., 

1891, xix, 294-304, 325-359. 
Hodgson, A. J., Treatment of Diabetes Mellitus, /. Am. Med. Assn., 1911, Ixvii, 

1187-1191. Diabetes Mellitus, Canad. Med. Assn. J., 1912, xli, 874- 

891. 
Homans, J., A Study of Experimental Diabetes in the Canine and Its Relation 

to Human Diabetes, /. Med. Research, 1915-16, xxxiii, 1-51. 
Home, F., Clinical Experiments, Histories, and Dissections, Edinburgh, 1780. 

Ref. in texts. 
Hopkins, F. G., Dr. Pavy and Diabetes, Science Prog., 1912, vii, 13-47. 
IwAi, T., Le diabete sucr6 chez les Japonais, et son 6tude comparative avec le 

diabete observg en Europe et en Am6rique, Arch. mid. exp. et anat. 

path., 1916, xxvii, 1-54, translation by J. LeGoS. 
Jastrowitz, H., Experimentelle Untersuchungen iiber die therapeutische Wir- 

kungsweise des Hafermehles, Z. exp. Path. u. Therap., 1912-13, xii, 

207-220. 



70 CHAPTER I 

Jonas, L., and Pepper, 0. H. P., Acute Diabetes with Enormous Elimination of 

Nitrogen: Report of Case with at Least Temporary Recovery, /. Ant. 

Med. Assn., 1917, kviii, 1896-1897. 
Jones, N. W., On the Clinical Application of the Newer Methods of Treatment 

of Diabetes Mellitus, Northwest Med., 1917, xvi, 38-41. 
JosLiN, E. P., (1) Present-Day Treatment and Prognosis in Diabetes, Am. J. 

Med. Sc, 1915, cl, 485-496. 

(2) Carbohydrate Utilization in Diabetes, Arch. Int. Med., 1915, xvi, 693- 

732. 

(3) Pregnancy and Diabetes Mellitus, Boston Med. and Surg. J., 1915, 

clxxiii, 841-849. 

(4) The Treatment of Diabetes Mellitus, Philadelphia and New York, 1916, 

2nd edition, 1917. 
JosLiN, E. P., Brigham, F. G., and Hoenor, A. A., An Analysis of Fourteen 

Cases of Diabetes Mellitus Unsuccessfully Treated by Fasting, 

Boston Med. and Surg. J., 1916, clxxiv, 371-378, 425-429. 
Kahn, M., and Kahn, M. H., Lime Therapy of Diabetes, Med. Rec, 1915, 

Ixxxviii, 744-746. 
The Lime Deficiency of Diabetes, Arch. Int. Med., 1916, xviii, 212-227. 
Kaeell, P., De la cure de lait, Arch. gin. med., 1866, (2), 513-533, 694-704. 
Kaulich, J., Ueber Acetonbildung im thierischen Organismus, Vrtljschr. prakt. 

Heilk., 1860, Ixvii, 58-72. 
Klemperer, G., (1) Ueber regulatorische Glykosurie und renalen Diabetes (Dis- 
cussion), Berl. klin. Woch., 1896, xxxiii, 571. 
(2) Die Verwertung reinen Traubenzuckers bei schweren Diabetikern, 

Therap. Gegenw., 1911, lii, 447-452. 
KoLiscH, R., (1) Lehrbuch der diatetischen Therapie, Leipsic and Vienna, 

1899. 
(2) Zur d'atetischen Behandlung des Diabetes mellitus, Wien. klin. Woch., 

1899, xii, 1305-1308. 
KOLISCH, R., and Schuman-Leclerq, F., Zur Frage der Kohlehydrattoleranz 

der Diabetiker, Wien. klin. Woch., 1903, xvi, 1321-1323. 
KtJLZ, R. E., (1) Beitrage zur Pathologie und Therapie des Diabetes mellitus, 

Marburg, 1874. 

(2) Klinische Erfahrungen tiber Diabetes mellitus, (Rumpf, AldehoflF, 

Sandmeyer), Jena, 1899. 

(3) Zur Prioritatsfrage bezuglich der Oxybuttersaure im diabetischen Harn, 

Arch. exp. Path. u. Pharm., 1884, xviii, 290. 
KussMAUL, Zur Lehre vom Diabetes mellitus, Deutsch. Arch. klin. Med., 1874, 

xiv, 1-46. 
Labbe, M., (1) Tol6rance comparee des divers hydrates de carbone par I'organ- 

isnie des diabetiques, Bull, et mim. Soc. mid. Mp. Paris, 1907, xxiv, 

221-234. 



Ref. by L6pine 
and Sauerbeck. 



HISTORY 71 

Labbe, M., (2) La cure de Mgumes sees chez les diabetiques, Bull, Acad, med., 
1914, Ixxi, 52-54. 

(3) Die Diat beim Diabetes gravis, Med. Klin., 1913, ix, 1973-1978. 

(4) Les cures de 16gumes sees dans le diabete, Rev. med., 1914, xxxiv, 

473-503. 
Lampe, E., Haferkuren bei Diabetes mellitus, Z. physik. u. diiUet. Therap., 1909-10, 

xiii, 213-231. 
Lampe, E., and Strassner, H., Blutzuckerwerte der verschiedenen Diatformen 

bei Diabetes, Med. Klin., 1913, ix, 1462-1465. 
Lancereaux, E., (1) Note sur un cas de syphilis pulmonaire, 

suivie de reflexions sur la syphilis des visceres 

et les erreurs dont elle est I'objet, Bull. Acad. 

mid., 1877, vi, 1108-1120. 

(2) Nouveaux faits de diabete sucre avec alteration du 

pancreas, Ihid., 1888, xix, 588-609. 

(3) Le diabete maigre: ses sympt6mes, son evolution, 

son prognostic et son traitement; ses rapports 
avec les alt6rations du pancreas. — fitude com- 
parative du diabete maigre et du diabete gras, 
Union Med., 1880, xxix, 161-167; 205-211. Lcfons 
de clinique medicale (Review), /6«i.,1890, xiv, 
439-441. 

Lapierre, a., Sur le diabete maigre dans ses rapports avec les alterations du 
pancreas, These de Paris, 1879. Ref. by Lepine and Sauerbeck. 

Latham, J., Facts and Opinions concerning Diabetes, London, 1811. 

Lemann, 1. 1., The Allen Treatment in Diabetes by Fasting, /. Am. Med. Assn., 
1915, Ixv, 2118. 

Lenn£, a., (1) Wesen, Ursache, und Behandlung der Zuclierkrankheit, Berlin, 
1898. 

(2) Die Eiweisszufuhr in der Diabetesdiat, Verhandl. Cong. inn. Med., 

1900, xviii, 587-600. 

(3) Ein weiterer Beitrag zur Diatregelung und medikamentosen Behand- 

lung des Diabetes mellitus, Therap. Gegenw., 1907, ix, 251-255. 
Leo, H., Ueber die Stickstoffausscheidung der Diabetiker bei Kohlehydratzu- 

fuhr, Z. klin. Med., 1893, xxii, 225-244. 
Lepine, R., (1) Le diabete sucre, Paris, 1909. 

(2) Fortschritte in der Behandlung des Diabetes mellitus seit 50 Jahren, 

Berl. klin. Woch., 1913, 1, 477-481. 

(3) Progres de nos connaissances sur la pathogenic et le traitement du 

diabete sucre et de I'acetonSmie, Rev. med., 1913, xxxiii, 449-473, 
601-624, 769-783. 
Levy, L. H., Diabetes. The Complications and Treatment; the Allen Plan, 
N. Y. Med. J., 1915, cii, 1192-1195. 



72 CHAPTER I 

Leyton, O., (1) Discussion on the Treatment of Diabetes Mellitus by Alimentary 
Rest, Proc. Roy. Soc. London, 1915-16, ix, Therap. and Pharm. 
Sect., 63-76. Also 76-90, (Spriggs). 

(2) The Treatment of Diabetes Mellitus by Alimentary Rest, Practitimer, 

1916, xcvii, 24-43, 401-429. 

(3) The Modem Treatment of Diabetes Mellitus, Brit. Med. J., 1917, 

i, 252-^254. 
LiPETZ, S., Ueber die Wirkung der v. Noorden'schen Hafercur beim Diabetes 

melitus, Z. klin. Med., 1905, Ivi, 188-197. 
LovEWELL, C. H., Modern Treament of Diabetes, Illinois Med. J., 1917, xxxi, 

240-245. 
Lrsz, G., (1) The Elements of the Science of Nutrition, Philadelphia, 2nd 
edition, 1909; 3rd edition, 1917. 
(2) Metabolism in Diabetes, /. Am. Med. Assn., 1910, Iv, 2105-2107. 
Magendie, (1) Note sur la prfisence normale du sucre dans le sang, Compt. 
rend. Acad., 1846, xxiii, 189-193; Gaz. mSd., 1846, 734-736, ref. Vogel, 
J., Pathologic des Bluts, Canstatt's Jahresh., 1846, iii, 27. 
Magnus-Levy, A., (1) Die Oxybuttersaure und ihre Beziehungen zum Coma 
diabeticum. Arch. exp. Path. u. Pharm., 1899, xlii, 149-237. 
(2) Diabetes mellitus, SpezieUe Pathologic und Therapie innerer Krank- 
heiten (Kraus and Brugsch), 1913, i, Tl. 1, 1-85. 
Mandel, a. R., and Lusk, G., (1) Diabetes Mellitus. — Report on a Case, Includ- 
ing a New Method of Prognosis, /. Am. Med. Assn., 1904, xUii, 241. 
(2) StofiEwechselbeobachtungen an einem FaUe von Diabetes mellitus, mit 
besonderer Beriicksichtigung der Prognose, Deutsch. Arch. klin. 
Med., 1904, Ixxxi, 472-492. 
Marsh, H., Observations on the Treatment of Diabetes Mellitus, Dublin Quart. 

J. Med. Sc, 1854, xvii, 1-19. 
Marshall, M., The Starvation Treatment of Diabetes, /. Michigan Med. Soc, 

1916, XV, 150-151. 
Martin, C. F., and Mason, E. H., Observations on the Starvation Treatment of 

Diabetes, Am. J. Med. Sc, 1917, cliii, 50-58. 
McNabb, E., The Treatment of Diabetes after the Method of Allen, /. Ten- 
nessee State Med. Assn., 1915-16, viii, 477-481. 
Menke, J., Ueber das Verhalten des Blutzuckers bei Kohlehydratkuren und tiber 
den Wert der Blutzuckerbestimmungen fur die Therapie des Dia- 
betes, Deutsch. Arch. klin. Med., 1914, cxiv, 209-248. 
VON Mering, J., (1) Ueber die Abzugswege des Zuckers aus der Darmhohle, 
Arch. Physiol., 1877, 379-415. 

(2) Ueber experimentellen Diabetes, Kong. inn. Med., 1886, v, 185-189. 

(3) Behandlung des Diabetes mellitus und insipidus, Handbuch spez. 

Therapie, Renzoldt and Stintzing, 1895, ii, 3te. Abt., 59-104. 
VON Mering, J., and Minkowski, 0., Diabetes mellitus nach Pancreasexstirpa- 
tion. Arch. exp. Path., u. Pharm., 1889-90, xxvi, 371-387. 



HISTORY 73 

M'Gregoe, R., Comparative State of Urea in Healthy and Diseased Urine, and 
the Seat of the Formation of Sugar in Diabetes Mellitus, London 
Med. Gaz., 1837, xx, 268-272. 

MiALHE, L., (1) Apercu theorique sur la cause de la maladie d6signee sous le 
nom de diab&te ou de glycosurie, Compt. rend. Acad., 1844, xviii, 707. 

(2) De la digestion et de I'assimilation des matieres sucrees et amiloides, 

Ibid., 1845, XX, 954-959. 

(3) Traitement raisonne du diabete par les substances alcalines, /. mSd. et 

ckir. prat., 1846, xvii, 23-24; Formule du traitement du diabete sucr6 
par les substances alcalines, Ibid., 77-78; ref. Vogel, J., Pathologie 
des Bluts, Canstatt's Jahresb., 1846, iii, 29. 

(4) NouveUes recherches sur la cause et le traitement du diabete sucre ou 

glucosurie. Bull. Acad, mid., 1847, xiii, 1224; Bull, therap., 1849, 
xxxvi, 198-208. Ref. by Lepine. 

(5) Nouvelle th6orie du diabete sucr6 ou glycosurie. Union Mid., 1866, 

XXX, 218-221, ref. by Lepine; also Arch. gin. mid., 1866, i, 746. 
MiALHE, L., and Contour, Observation d'un cas de diabete sucr6 traits et gueri 

par I'emploi des alcalis et des sudorifiques, Compt. rend. Acad., 1844, 

xix, 111-112. 
Minkowski, O., (1) Ueber das Vorkommen von Oxybuttersaure im Ham bei 

Diabetes mellitus. Arch. exp. Path. u. Pharm., 1884, xviii, 35-48. 

(2) Nachtrag iiber Oxybuttersaure im diabetischen Harne, Ibid., 147-150. 

(3) Untersuchungen iiber den Diabetes mellitus nach Exstirpation des 

Pankreas, Ibid., 1892-3, xxxi, 85-189. 

(4) Die neueren Anschauungen iiber den Diabetes mellitus, Med. Klin., 

1911, vii, 1031-1036. The Newer Opinions concerning Diabetes 
Mellitus, translation by G. Lusk, Med. Rec, 1913, Ixxxiii, 220-225. 

MosENTHAL, H. 0., The Treatment of Diabetes Mellitus in Dispensaries, Med. 
Rec, 1915, Ixxxvii, 589-592. 

Moses, H. M., The Present Treatment of Diabetes Mellitus, Med. Rec, 1916, 
xc, 1069-1072. 

MossE, A., La cure de pommes de terje dans les diabetes sucr6s et les compli- 
cations diabetiques. Rev. mid., 1902, xxii, 107-121, 279-308, 371- 
411, 620-658, 1098. 

Naunyn, B., (1) Zur Pathologie und Therapie des Diabetes mellitus, Verhandl. 
Cong. inn. Med., 1886, v, 183-184. 

(2) Die diatetische Behandlung des Diabetes mellitus, Samml. klin. Vortr., 

1889, (Innere Medicin, No. 116), 3129-3168. 

(3) Nephritis und Diabetes und Nierendiabetes, Z. prakt. Aerzie., 1898, vii, 

525-530. 

(4) Der Diabetes melitus, Deutsch. Klin., 1902, iii, 1-34. 

(4A) Die Behandlung des Diabetes melitus, Deutsch. med. Woch., 1905, 
xxxi, 977-982. 



74 CHAPTER I 

Naunyn, B., (S) Der Diabetes melitus, Vienna, 1906. 

(6) Diatetische Behandlung der Glykosurie und des Diabetes, Z. artzl. 

FortUld., 1908, v, 737-746. 
Nesbitt, G. E., Remarks on the Alien Treatment of Diabetes, Dublin J. Med. 

Sc, 1916, cxlii, 379-385. 
Nicolas, and Gueudeville, V., Recherches et experiences medicales et chimi- 

ques sur le diabete sucre ou la phthisurie sucree, Paris, 1803. Ref. 

by Sauerbeck and others. 
VON NoOEDEN, C., (1) Die Zuckerkrankheit und ihre Behandlung, Berlin, 6th 
• edition, 1912. 

(2) New Aspects of Diabetes, New York, 1912. 

(3) Die Diat bei Diabetes gravis, Med. Klin., 1913, ix, 611-616. 

Opie, E. L., (1) On the Relation of Chronic Interstitial Pancreatitis to the Islands 

of Langerhans and to Diabetes Mellitus, /. Exp. Med., 1900-1901, v, 

397-428. 
(2) Diabetes MeUitus Associated with Hyalin Degeneration of the Islands 

of Langerhans of the Pancreas, Bull. Johns Hopkins Hosp., 1901, 

xii, 263-264. 
Opplee, B., and KiJLZ, C., Ueber das Vorkommen von Diabetes mellitus bei 

Ehegatten (Uebe'rtragbarkeit des Diabetes mellitus), Berl. klin. 

Woch., 1896, xxxiii, 583-586, 612-615. 
Paley, S. H., The Allen Treatment in Diabetes MeUitus, N. Y. Med. J., 1916, 

ciii, 159-161. 
Palmer, W. W., The Concentration of Dextrose in the Tissues of Normal and 

Diabetic Animals, /. Biol. Chem., 1917, xxx, 79-114. 
Palmer, W. W., and Van Slyke, D. D., Studies of Acidosis. IX. Relationship 

between Alkali Retention and Alkali Reserve in Normal and Tatho- 

logical Individuals, /. Biol. Chem., 1917, xxxii, 499-507. 
Pavy, F. W., (1) Researches on the Nature and Treatment of Diabetes, London, 

1862. 

(2) The Physiology of the Carbohydrates, London, 1894. 

(3) Carbohydrate Metabolism and Diabetes, London, 1906. 
Petersen, V. C. E., Von der Wirkung der " Kohlenhydrattage" in der Dia- 

betesbehandlung, Deuisch. med. Woch., 1912, xxxviii, 1276-1278. 
von Petteneofer, M., and Voit, C, Ueber den Stoffverbrauch bei der Zucker- 

harnruhr, Z. Biol., 1867, iii, 380-444. 
Petters, W., Untersuchungen iiber die Honigharnruhr, Vrtljschr. prakt. Heilk., 

1857, iii, 81-94. 
PiORRY, Sur un nouveau systeme de medication employe avec succes dans le 

diabete sucre, Compt. rend. Acad., 1857, xliv, 133-134. (Abstract.) 
PiSKATOR, O., Ueber den Erfolg der Haferkur bei Diabetes mellitus. Inaugural 

Dissertation, Giessen, 1912. 
Popper, M.^ Das Verhaltnis des Diabetes zu Pankreasleiden und Fettsucht, 

Osterreich Z. prakt. Heilk., 1868, xiv, 193-196. Ref. by Sauerbeck. 



HISTORY 75 

Potter, N. B., Cure de jeflne d'Allen pour le diabete sucr6, Ann. mid., 1917, 

iv, 341-374. 
Prasad, K., Experiences in Diabetes Mellitus in the East, Seventeenth Inter- 
national Congress of Medicine, London, 1913, vi (2), (Medicine), 

327-332. 
Prout, W., On the Nature and Treatment of Stomach and Renal Diseases, 

London, 1848. 
Rathery, M. F., (1) Les pommes de terre dans I'alimentation du diabetique, 

Bull, et mem. Soc. mid. h$p. Paris, 1911, xxxi, 160-173. 
(2) De I'alimentation parmentiere dans le diabete. La Clinique, 1913, viii, 

770-773. 
Ratjlston, B. O., and Woodyatt, R. T., Blood Transfusion in Diabetes Mellitus, 

J. Am. Med. Assn., 1914, Ixii, 996-999. 
Regnault, v., and Reiset, J., Recherches chimiques sur la respiration des ani- 

maux des diverses classes, Ann. chim. et phys., 1849, xxvi, 299-519. 

Ref. by Lusk. 
Reicher, K., Verhandl. deutsch. Kong. inn. Med., 1913, xxx, 179. 
Reynoso, a., Memoire sur la presence du sucre dans les urines, et sur la liaison 

du phenomene avec la respiration, Ann. sc. nat., 1855 (Zoologie), iii, 

120-153. Ref. by Lepine. 
Richardson, W., Remarks on Diabetes, London, 1871. 
Richartz, H. L., Kohlehydratkuren bei Diabetes, Deutsch. med. Woch., 1913, 

xxxix, 650^652. 
RoBBiNS, C. P., Observations and Experiences of the Allen Treatment, J. -Lancet, 

1917, xxxvii, 300-302. 
RoLLO, J., (1) An Account of Two Cases of the Diabetes Mellitus; with Re- 
marks, etc., London, 1797. Ref. in texts. 
(2) Cases of the Diabetes Mellitus, London, 2nd edition, 1798. 
ROLLY, F., Zur Theorie und Therapie des Diabetes mellitus, Deutsch. Arch. klin. 

Med., 1911-12, cv, 494-521. 
RosENPELD, G., Ueber die Entstehung des Acetons, Deutsch. med. Woch., 1885, 

xi, 683-685. 
Roth, N., Ueber Mehltage bei Diabetes, Wien. klin. Woch., 1912, xxv, 1864-1868. 
ROTJBITSCHEK, R., and Gaupp, 0., Die Kohlehydrattherapie des Diabetes, Med. 

Klin., 1913, ix, 1038-1041. 
RuMPE, T., (1) Ueber die Assimilationsgrosse und den Eiweissumsatz beim 

Diabetes mellitus, Berl. klin. Woch., 1898, xxxv, 945-948. 

(2) Ueber Eiweissumsatz und Zuckerausscheidung beim Diabetes mellitus, 

Ibid., 1899, xxxvi, 185-189. 

(3) Untersuchungen iiber Diabetes mellitus, Z. klin. Med., 1902, xlv, 

260-313. 
Salomon, M., Geschichte der Glycosurie von Hippokrates bis zum Anfange des 
19. Jahrhunderts, Deutsch. Arch. klin. Med., 1871, viii, 489-582. 



76 CHAPTER I 

Sauerbeck, E., Die Langerhansschen Inseln des Pankreas und ihre Beziehung 

zum Diabetes mellitus, Ergebn. dig. Path. u. path. Anal., 2te Abt., 

1902, viii, 538-697. 
Saundby, R., Diabetes Mellitus, in Allbutt and Rolleston's System of Medicine, 

London, 1908, iii, 167. 
ScHiFF, J. M., Untersuchungen iiber die Zuckerbildung in der Leber,' und den 

Einfluss des Nervensystems auf die Erzeugung des Diabetes, Wiirz- 

burg, 1859. 
ScHU-LiNG, Inaugural Dissertation, Leipsic, 1911. Ref. by Joslin (2) and by 

RoUy. 
ScmEOKAUER, H., Haferkur und Blutzuckergehalt bei Diabetes mellitus, Berl. 

klin. Woch., 1912, xlix, 1129-1132. 
ScHMiTZ, R., (1) 4 Falle von geheiltem Diabetes und kurze Bemerkungen iiber 

die Entstehung desselben, Berl. klin. Woch., 1873, x, 211-214, 222- 

224. 
(2) Kann der Diabetes mellitus ubertragen werden? Ibid., 1890, xxvii, 

449-451. 
ScHNEE, E., Diabetes, Its Cause and Permanent Cure, 1889, translation by 

R. L. Tafel. 
Seegen, J., Der Diabetes mellitus, Leipsic, 1870. 
Senator, H., Ueber das Vorkommen von Diabetes mellitus bei Eheleuten und 

die Uebertragbarkeit des Diabetes, Berl. klin. Woch., 1896, xxxiii, 

665-666. 
Severin, Kohlehydratkuren bei Diabetes mellitus unter besonderer Beruck- 

sichtigung des Blutzuckers, Berl. klin. Woch., 1912, xlix, 2010-2011. 
Spriggs, E. I., (1) Discussion on the Treatment of Diabetes Mellitus by Ali- 
mentary Rest, Proc. Roy. Soc. London, 1915-16, ix, Therap. and 

Pharm. Sect., 76-90. Also 63-76, (Leyton). 
(2) The Fasting Treatment of Diabetes, Brit. Med. J., 1916, i, 841-845. 
Stadelmann, E., Ueber die Ursachen der pathologischen Ammoniakausscheidung 

beim Diabetes mellitus und des Coma diabeticum. Arch. exp. Path. 

u. Pharm., 1883, xvii, 419-444. 
Staubli, C, Beitrage zu Pathologie und Therapie des Diabetes mellitus, Deutsch. 

Arch. klin. Med., 1908, xciii, 107-160. 
Stengel, A., Diabetes, Progr. Med., June, 1915, 393-407; June, 1916, 426-440. 
Stengel, A., Jonas, L., and Austin, J. H., The Treatment of Diabetes Mellitus 

with Special Reference to Allen's Method, Pennsylvania Med. J., 

1915-16, xix, 283-287. 
Stetten, De W., The Conservative Treatment of Diabetic Gangrene of the 

Lower Extremity, J. Am. Med. Assn., 1913, Ix, 1126-1133. 
Stillman, E., The Fasting Treatment of Diabetes Mellitus, with Special Reference 

to Acidosis, Am. J. Med. Sc, 1916, cli, 505-515. 



HISTORY 77 

Stillman, E., Van Slyke, D. D., Cullen, G. E., and Fitz, R., Studies of 

Acidosis. VI. The Blood, Urine, and Alveolar Air in Diabetic 

Acidosis, 7. Biol. Chem., 1917, xxx, 405-456. 
SxoKVis, B. J., Zur Pathologie und Therapie des Diabetes naellitus, Deutsch. 

Kong. inn. Med., 1886, v, 125-159. 
SxROUSE, S., (1) Diabetes in the Young, Med. Clin. Chicago, 1916, ii, 2, 327-338. 
(2) Inanition in the Treatment of Diabetes Mellitus, Ibid., 1917, ii, 5, 

999-1006. 
Thomson, R. D., On the Digestion of Vegetable Albumen, Fat, and Starch, The 

London, Edinburgh and Dublin Philosophical Magazine, 1845, xxvi, 

322-328, 418-424. Ref. by Pfliiger. 
TiEDEMANN, F., and Gmelin, L., Die Verdauung nach Versuchen, Heidelberg 

and Leipsic, 1826-27, i. 
Trommer, Unterscheidung von Gummi, Dextrin, Traubenzucker und Rohr- 

zucker, Pharm. Centr., 1841, 762-764. 
Trousseau, A., Lectures on Clinical Medicine, translated from edition of 1868 

by J. R. Cormack, London, 1869, iii, 491-527, Lecture Ixiv, "Glyco- 
suria: Saccharine Diabetes." 
Tyson, J., A Treatise on Bright's Disease and Diabetes, Philadelphia, 1881 and 

1904. 
Van Slyke, D. D., and Cullen, G. E., Studies of Acidosis. I. The Bicarbonate 

Concentration of the Blood Plasma; Its Significance, and Its Deter- 
mination as a Measure of Acidosis, J. Biol. Chem., 1917, xxx, 289- 

346. 
Van Slyke, D. D., Studies of Acidosis. II. A Method for the Determination of 

Carbon Dioxide and Carbonates in Solution, J. Biol. Chem., 1917, 

xxx, 347-368. 
Van Slyke, D. D., Stillman, E., and Cullen, G. E., Studies of Acidosis. V. 

Alveolar Carbon Dioxide and Plasma Bicarbonate in Normal Men 

During Digestive Rest and Activity, J. Biol. Chem., 1917, xxx, 

401-404. 
Van Slyke, D. D., Studies of Acidosis. VII. The Determination of /3-Hydroxy- 

butyric Acid, Acetoacetic Acid, and Acetone in Urine, /. Biol. Chem., 

1917, xxxii, 455-493. 
Van Slyke, D. D., and Fitz, R., Studies of Acidosis. VIII. The Determination 

of /3-Hydroxybutyric Acid, Acetoacetic Acid, and Acetone in Blood, 

J. Biol. Chem., 1917, xxxii, 495-497. 
Walter, F., Untersuchungen Uber die Wirkung der Sauren auf den thierischen 

Organismus, Arch. exp. Path. u. Pharm., 1877, vii, 148-178. 
Warren, P., Two Cases of Diabetes Mellitus Treated with Opium, Med. Tr. 

College Phys. London, 1813, iv, 188-225. 
Waters, E. E., The Treatment of Diabetes by Alimentary Rest, Indian Med. 

Gaz., 1917, Hi, 42-46. 



78 CHAPTER 1 

Watt, R., Cases of Diabetes, Consumption, etc., with Observations on the His- 
tory and Treatment of Disease in General, Paisley, 1808. 
Weichselbaum, a., (1) Ueber die Veranderungen des Pankreas bei Diabetes 

mellitus, Sitzungsb. kais. Akad. Wissensch., 1910, cxix, 73-281. 
(2) Ueber die Veranderungen des Pankreas bei Diabetes melitus, Wien. 

klin. Woch., 1911, xxiv, 153-159. 
Weichselbaum, A., and Stangl, E., (1) Zur Kenntnis der feineren Veranderungen 

des Pankreas bei Diabetes mellitus, Wien. klin. Woch., 1901, xiv, 

968-972. 
(2) Weitere histologische Untersuchungen des Pankreas bei Diabetes 

mellitus, lUd., 1902, xv, 969-977. 
Weiland, W., Kohlehydratkuren und Alkalitherapie bei Diabetes mellitus; ihre 

Indication und Prognose, Z. exp. Path. u.. Tkerap., 1912-13, xii, 

116-151. 
Weintraud, W., Untersuchungen iiber den Stoffwechsel im Diabetes mellitus 

und zur diatetichen Therapie der Krankheit, Bibliotheca medica, 

1893, Abt. D', No. I. 
Werbitzki, F. W., Zur Frage des Einflusses der verschiedenen Kohlehydrate auf 

die Glykosurie der Diabetiker, Z. exp. Path. u. Therap., 1909, vi, 

235-253. 
Williams, J. R., Recent Studies in Diabetes Mellitus, N. Y. Slate J. Med., 

1916, xvi, 412-418. 
Williamson, R. T., (1) Diabetes Mellitus and Its Treatment, Edinburgh and 

London, 1898. 

(2) On the Treatment of Diabetes Mellitus with Casein and Cream, Brit. 

Med. J., 1915, i, 456-458. 

(3) The Treatment of Diabetes Mellitus, Lancet, 1917, i, 650-652. 
Winternitz, W., and Strasser, A., Strenge Milchkuren bei Diabetes mellitus, 

Centr. inn. Med., 1899, xx, 1137-1139. 
WoLE, L., and Gutmann, S., In welcher Weise wirken Diatkuren auf das Ver- 

halten des Blutzuckers bei Diabetikern? Z. klin. Med., 1914, Ixxix, 

394^420. 
Wolfe, W., Ueber Mehlkuren und Kartofielkuren bei Diabetes, If ed.^/iw., 1913, 

ix, 789-790. 
Woodyatt, R. T., (1) Prepared Foods and Diabetic Articles, Illinois Med. J., 

1909, xvi, 666-674. 

(2) Discussion, Tr. Assn. Am. Phys., 1915, xxx, 339-340. 

(3) Am. Sac. Advancement Clin. Investigation, 1915, Abstract of Proceed- 

ings, 25-28. 
ZiMMER, K., (1) Ein Beitrag zur Lehre vom Diabetes mellitus, Deutsch. Klin., 
1867, xix, 127-128, 133-136, 149-152, 160-162. 

(2) Die nachste Ursache des Diabetes mellitus, Ihid., 1871, xxiii, 41-42. 

(3) Der Diabetes mellitus, sein Wesen und seine Behandlung, Leipsic, 1871. 

(4) Die Muskeln als Quelle des Zuckers im Diabetes mellitus, Deutsch. 

Klin., 1873, xxv, 61-62. 



CHAPTER II. 
GENERAL PLAN OF TREATMENT. 

This chapter, like the later ones, aims only to present the methods 
and experience of the present investigation. A multitude of ques- 
tions and details concerning the treatment of diabetes must neces- 
sarily be left to general text-books on the subject. Discussion of the 
observations and suggestions of others who have used this treatment 
must also for the most part be omitted in the interests of brevity. 
For details of the laboratory methods employed, reference may be 
made to the original papers or to the excellent description in Joslin's 
text-book. 

As emphasized from the outset, every case of diabetes must be 
managed according to its own requirements, and the best results are 
obtainable only when the treatment is intelhgently individualized. 
At the same time, a basic plan is essential, inasmuch as one general 
principle underhes the treatment of all cases, and organization and 
routine conduce to both ease and efl&ciency. The system developed 
in this hospital may be described under the following headings: 

I. General measures. 

II. Treatment up to cessation of glycosuria in simple cases. 

III. Complications and emergencies (acidosis, infections). 

IV. Treatment following cessation of glycosuria. 
V. Ideals of diet and laboratory control. 

VI Practical management of diets. 



79 



I. General Measures. 

A. The Routine Care of Patients. 

1. Hospital Observation.^AH. the cases treated have been under 
direct hospital observation. Between February 24, 1914, and July 
1, 1917, altogether 96 patients were received, for a total of 165 ad- 
missions, an average of 1.72 admissions to each patient. The great- 
est number of admissions for a single patient was five. The total 
number of days of diabetic treatment was 11,308, giving an average 
of nearly 69 days to each admission. The longest single admission 
was 304 days, the shortest a few hours (acute death). Hospital ob- 
servation has seemed advisable for the following reasons: (a) to obviate 
possible danger from acidosis during the active treatment of the dis- 
ease by the fasting method; (b) to govern with the greatest possible 
accuracy the individual diet, while the preliminary tests of tblerance 
are being made, a ration built up, and its suitability demonstrated; 
(c) for the instruction of the patient, in order that he may carry out 
his diet and tests properly after leaving the hospital. 

2. Confinement to Bed. — ^Unless made advisable by some complica- 
tion or by a dangerous degree of acidosis, the patients have not been 
confined to bed. Even during the most trying period of treatment, 
namely the initial fast, it has not been uncommon for patients to lessen 
the tedium of treatment by going to theatres, concerts, etc. 

J. Clothing. — ^As many patients show a decided susceptibility to 
cold weather, they have been advised to dress wannly, but without 
specific instructions. The use of exercise, as discussed in Chapter V, 
has obviated this condition to some ^tent, especially for that great 
majority of diabetic cases which rank as relatively mild. But the 
extremely low diets required for the very severe cases provide so 
little combustible material that body heat must be conserved as care- 
fully as possible. 

4. Baths. — It has not been attempted to gain effect through hydro- 
therapy. Bath temperature has been left to individual inclination. 
Patients with severe diabetes have naturally chosen warm water. 

80 



GENERAL PLAN OF TREATMENT 81 

5. Catharsis. — Chronic and obstinate constipation has been a rule 
with few exceptions in the past history of these as of other severely 
diabetic patients. It was regulated by cathartics before bran was 
incorporated into the dietary of the hospital. This and the bulky 
vegetables have almost banished constipation. When something 
more active has been needed, the usual cathartics (castor oil, salts, 
cascara sagrada) have been employed. 

6. Medication. — The principle has been followed of giving drugs 
to diabetic patients only as they would be used for other persons. No 
medicines have been employed with a view to influencing the dia-. 
betes, and no effect upon the diabetes has been observed from any of 
those employed for incidental purposes. The recommendations of 
various drugs in the past have probably been based upon inadequate 
control and study of the cases. Special mention may be made of the 
dangerous possibilities of anesthetics, especially chloroform. It is well 
known that drugs of the chloroform class most easily injure the liver 
when it is poor in glycogen. The visceral disturbances set up by 
general anesthesia readily explain the production of either glycosuria 
or acidosis, as so frequently described. The dangers are greatest 
where the treatment is poorest, and the majority of diabetics under 
thorough treatment are able to undergo suitable anesthesia without 
glycosuria and without dangerous acidosis. 

7. Complications. — The experience with these has not been large. 
It is discussed in Chapter VII and in the individual case histories. 
The treatment of the acute forms is described under Section III of 
the present chapter. Metabolic complications in general do not in- 
terfere with the treatment of the diabetes; the present diabetic diet 
does not conflict, for example, with the usual treatment of nephritis. 
In regard to infectious complications, it may be said that the ideal of 
treatment is to make the patient as nearly like a normal person as 
possible by means of diet, and then to use as nearly as possible the 
measures considered best for normal persons. The recently debated 
question of the relation of infections, sometimes focal and minor in 
degree, to the etiology of diabetes is discussed in Chapter VIII. 
Certainly bad tonsils, teeth, and other foci are sources of injury for 
diabetic patients, which in acute attacks often give rise to glycosuria 
and acidosis, and which may interfere seriously with the success of 



82 CHAPTER II 

dietetic treatment. It has been the policy with this series of cases to 
have teeth or tonsils removed or other operations performed on the 
same basis as advised for normal persons by conservative specialists. 
Experience has indicated that such measures are beneficial from the 
standpoint of the general health and also of the diabetes, in obviating 
chronic and acute disturbances and the downward progress associated 
with them. No patient has died or suffered harm from such opera- 
tions performed while on the dietetic treatment, and it appears that 
there is less danger from performing needed surgery than from 
omitting it. On the other hand, if toxic absorption causes diabetes, 
evidently the damage has mostly been done before the case has come 
under treatment, for in no instance has the removal of a focus of in- 
fection been followed by cure of the diabetes or by improvement 
beyond that seen in other patients. 

B. Ward Regulations and Clhstical Remarks. 

1. Respiration, pulse, and temperature have been recorded at 4 
hour intervals when fever was present or when acidosis or other 
crisis threatened. Otherwise they have been taken every 12 hours. 
Sohie of the information which may be gleaned from these signs in 
diabetic patients follows. 

Respiration. — Increased breathing is one of the classical indications 
of acidosis, the increase generally applying to both volume and fre- 
quency. Ordinarily it is a fairly constant and rehable index of danger, 
unless obscured by the use of alkali; but in the type of acidosis pro- 
duced by fasting, it may, like the drowsiness and other symptoms, 
be far less prominent than in typical diabetic coma. 

Pulse. — It may some day be possible to analyze the records of 
these cases with respect to the pulse rate. F. G. Benedict has noticed 
a relation between pulse and metabolism, and he and Joshn reported 
acceleration of the pulse in proportion to increased metabolism in 
severe cases of diabetes with active symptoms present. Patients in 
the present series entering the hospital with intense diabetes and 
threatening acidosis have regularly shown rapid pulse, which has 
become slower under treatment. A few examples appear in tables in 
certain of the case histories. Marked bradycardia has been observed 



GENERAL PLAN OF TREATMENT 83 

in some of the patients subjected to extreme undernutrition and the 
corresponding reduction of metabolism, but this has not been con- 
stant. The conditions are evidently not simple. On the one hand, 
the tachycardia out of proportion to any possible exaggeration of 
metabolism in impending coma is clearly an effect of intoxication upon 
the circulation. On the other hand, Dr. Alfred Cohn has observed 
in radiograms of some of these emaciated patients a diminution of the 
cardiac shadow even out of proportion to the thinning of the chest. 
This wasting of the heart muscle, like other states of general or circu- 
latory weakness, might of itself alter the rate, especially in the di- 
rection of tachycardia. With the uncertainty concerning the re- 
spective influence of metabohc and other factors, a uniform inter- 
pretation may be difficult. 

Temperature. — It being understood that the temperature of diabetic 
patients typically is normal, notice should be taken of variations in 
two directions. Elevation of temperature often accompanies severe 
acidosis, as illustrated in a few of the case records in this series. 
Otherwise, fever of any grade generally points to infection, and ceases 
with the finding and removal of the cause. Subnormal temperature 
■^is common in proportion to malnutrition, whether the latter is due 
to failure of assimilation of food with active diabetes, or to thera- 
peutic restriction of diet. In the most severe cases of this series under 
treatment, the rectal temperature has commonly been below 98° and 
above 96°F. An important practical point is to watch the tem- 
perature when children must be subjected to extreme xmdernutrition. 
Even though the weakness is not visibly graver than before, a fall of 
temperature to the neighborhood of 96-95°F. is a signal of danger, 
which generally comes in time to permit warding off death by giving 
food. If acidosis or stubborn glycosuria makes a full diet inad- 
visable, even protein alone may support strength to the point where 
fasting can be continued. More careful attention to this point 
might possibly have prevented the fatal collapse which occurred in 
several children of this series. The low temperatures in severely 
diabetic patients are readily explained by the failure to receive or to 
assimilate (according to the treatment) enough combustible material. 
The same circxunstance may wholly or partly explain another im- 
portant clinical phenomenon, namely the absence or diminished grade 



84 CHAPTER n 

of the febrile reaction to infection in some cases. Joslin called atten- 
tion to the possibility of an almost complete lack of symptoms with 
tuberculosis, even in an advanced stage. Something similar may be 
witnessed occasionally with other infections. Either the weakened 
individual is deficient in reactive power, or possibly the resultant of a 
subnormal temperature and a febrile tendency may be something like 
a normal temperature. This possible fallacy regarding fever should 
be borne in'mind, and if a patient under rigid dietary control begins 
to do badly without apparent cause, careful search should be made 
for the infection which is often responsible. 

2. Blood Pressure. — ^Aside from extraneous causes of hypertension, 
the blood pressure of diabetic patients is generally normal or below 
normal. Not only weakness, but also the intoxication of acidosis, is 
responsible for the depression. Several patients received in extreme 
stages have had a systolic blood pressure below 80, and in certain 
others the circulation was so feeble that it was not possible to deter- 
mine the pressure accurately. In such cases the question always arises 
whether the patient can endure the week or more of absolute fasting 
required to control his diabetes. In actual fact, every adult has 
passed successfully through such fasting, not only without collapse, 
but generally with more or less gain in strength, as indicated for one 
thing by a rise in blood pressure. It thus appeared that intoxication 
was the most dangerous factor in the depression, and relief from it 
even at the price of fasting was necessary to save life. Therefore a 
dangerously low blood pressure is not necessarily any contraindication 
to fasting. On the other hand, it is possible that a fall in blood pres- 
sure during fasting or extreme imdemutrition may be a signal of 
danger, but the clinical observations have not been sufl&cient to show 
whether this is a reliable warning or whether it comes in time to per- 
mit of averting the danger. 

3. Body Weight. — AU patients have been weighed naked each morn- 
ing after voiding urine and before breakfast. The weight has been 
recorded in kilograms. The weight is very valuable among the cri- 
teria of treatment, though it is well known to be only a crude measure 
of the true body mass. Patients with intense active diabetes some- 
times seem to be dried out by diuresis; they may hold or gain weight 
by water retention during fasting and for days or weeks on inadequate 



GENERAL PLAN OF TREATMENT 85 

diet thereafter. Fall in weight is sometimes sudden, to the extent of a 
kilogram or two on a fast-day, without evident significance. Fat diet 
following carbohydrate diet gives rise to such a water loss. The 
commonest cause of precipitous fall in weight for a series of days is 
acidosis. This melting away of weight and strength is seen in its 
most alarming degree in the occasional cases combining intense acido- 
sis, maximal D:N ratio, exaggerated nitrogen loss, and, with these, 
rapid water loss. The opposite condition of sudden gain in weight 
represents water retention, sometimes associated with relief from 
glycosuria or acidosis, or with carbohydrate feeding, but frequently 
from obscure cause. Even without nephritis, it is commonly con- 
nected with salt retention and removed by salt-free diet. It may 
differ in degree at different times and especially in different patients, 
from invisible storage to extensive edema. Edema, sometimes huge, 
has been well known in connection with the large salt intake in "oat- 
meal cures," and especially with high dosage of sodium bicarbonate. 
In Joslin's experience, water loss is one of the most dangerous, and 
water retention or edema one of the most favorable conditions when 
combating a dangerous acidosis. On the other hand, the more severe 
cases have the greatest tendency to edema. This edema may there- 
fore be classed among the indications of severity, though not aU 
severe cases show the tendency equally. Apart from any mere 
changes in the function of the kidney for salt, it is likely that there 
is some unknown metabolic cause affecting the general tissues, either 
belonging in some measure to diabetes itself, or perhaps largely or 
wholly a phenomenon of undernutrition. It may possibly belong in 
a series of dropsical conditions due to malnutrition, a related member 
being the "hunger swelling" ^ of the wretchedly poor classes in Poland 
on an almost exclusive potato diet in the present war, another re- 
presentative being the "epidemic dropsy"^ of famine times in India, 
another being the edema of cachectic children, while at the farther 
extreme is beri-beri. 

^Budzynski, B., and Chelkowski, K., abstracted in /. Trop. Med., 1916, xix, 
141-42. 

^Megaw, J. W. D., Indian Med. Gaz., 1910, xlv, 121; /. Am. Med. Assn., 
1911, Ivii. 826. 



86 CHAPTER n 

4. Measurement of Fluids. — It is well known and has lately been 
emphasized by DuBois that an accurate water balance is one of the 
hardest of all things to determine. In our cases the fluid intake and 
output have been measured daily, and occasionally gross retention 
or loss of water has been thus demonstrated. The information 
afforded is necessarily vague and inaccurate. No allowance was made 
for the water content of foods, and especially the large quantities of 
vegetables generally given made this unknown factor a considerable 
one. Most of the apparent discrepancies of intake and output 
shown in the graphic charts are thus explained. 

(a) Intake. — Thirst is not of abnormal degree in ordinary 
diabetic patients under proper treatment, one of the advantages of 
which is the relief from the discomfort of polydipsia and the incon- 
venience of polyuria and nycturia. Severely diabetic patients on 
very low diets generally drink rather freely, merely for the sake of 
something to fill the stomach. There has been no need to restrict 
fluids, except temporarily in a single patient (No. 1) who had formed 
the habit of excessive drinking, and in a few others during periods of 
marked edema. There is also no need to urge drinking of mineral 
waters or anything else under the conditions of proper diet, there 
being no poisons to wash out of the system. This may be an im- 
portant advantage in cases with a complicating nephritis, with lim- 
ited ability to excrete fluid. The one emergency which demands the 
forcing of fluids to capacity is dangerous acidosis, as mentioned later 
in this chapter. 

(b) Output. — If an occasional patient drinks so little that the urine 
is unduly concentrated, a troublesome turbidity may cloud the sugar 
reactions; and instead of using chemical reagents for clearing, the best 
plan all around may be to urge the patient to drink a normal quantity 
of water. Usually in the severe cases the urine is very pale and clear, 
both because of the excessive drinking stimulated by hunger and be- 
cause of the small total content of solids. It thus resembles in appear- 
ance the traditional diabetic urine, but a sharp difference is found in 
the very low specific gravity. Delicate sugar reactions are easily 
seen. The total 24 hour urine is saved in four separate portions each 
day, the divisions coming at mealtimes. During all the earlier and 
greater part of the investigation, days were counted from 7 a.m. of 



GENERAL PLAN OF TREATMENT 87 

one day to the same hour the next day. More recently, for general 
hospital convenience, a change has been made to the less commenda- 
ble method of counting from midnight to midnight. Accordingly 
at present the order of periods is as follows: 

Period I. Midnight to 7 a.m. 
Period U. 7 a.m. to 11:30 a.m. 
Period III. 11:30 a.m. to 5:30 p.m. 
Period IV. 5:30 p.m. to midnight. 

Two considerations favor this latter plan, namely that all urine is re- 
corded under the date on which it was voided instead of being dis- 
tributed over two dates, and second that the separation of days is 
made at a time when there is little work in the hospital instead of at 
the busy hour of 7 a.m. The arguments against this plan and in 
favor of the former plan are more weighty, first that patients are sub- 
jected to the inconvenience of being wakened at midnight to void 
urine, and second that the urine of a day does not correspond cor- 
rectly to the diet of the day, inasmuch as the break between days is 
made at a time when the digestion of the last meal is not finished. 
The segregation in four periods has a decided value. Patients are 
not free from glycosuria unless the test is absolutely negative in every 
period. Even when the reaction seems negative in the mixed 24 
hour urine, tests of the separate specimens may show not only the 
presence of faint traces but also after which meal they appeared. 
Also a transgression of diet is sometimes revealed by a marked reac- 
tion occurring suddenly in some period and clearing up thereafter, 
whereas a slight reaction in the mixed 24 hour urine might be of doubt- 
ful interpretation. 

5. Meals. — Food has generally been served in three meals, with 
sometimes an additional lunch at bedtime. In the past, minor pecu- 
liarities in the relation between meals and glycosuria have been de- 
scribed, generally glycosuria after carbohydrate ingestion and clear- 
ing up during the night, more rarely glycosuria only at night, absent 
during the day perhaps because of exercise. Also, it seems a promis- 
ing plan to give carbohydrate distributed in nmnerous small fractions 
at intervals, or in slowly digestible form, so as to avoid flooding 



88 CHAPTER II 

the system suddenly; and from such work as that of Thomas,' 
it might appear that the best assimilation of protein would be ob- 
tainable by the same scheme. Undoubtedly it is possible to flood the 
system, especially with a quickly absorbable carbohydrate such as 
sugar, when the same quantity in divided doses would be assimilated 
without glycosuria. But under the ordinary conditions of diabetic 
treatment, the essential cause back of either regular or irregular 
glycosuria is a diet in excess of the tolerance or a persistently high 
blood sugar. As for distribution of foods between meals, a mild case 
of diabetes on a proper diet should be independent of such variations 
within limits of reason. With severe cases, the difficulty lies in the 
persistence of the hyperglycemia set up by either carbohydrate or 
protein, so that before the effect of one ingestion has subsided the next 
is superimposed upon it. In general, the total diet is the important 
thing, and httle is to be hoped from unusual fractionation. A ration 
so close to the verge of tolerance as to require such aid will not be 
permanently tolerated. On the other hand, when the blood sugar 
is kept normal by a total diet truly within the assimilative power, 
glycosuria or other trouble does not result from any arrangement of 
meals that is likely to be made. 

6. Regulation of Habits. — Precision regarding diet has been the 
chief essential. In other matters, it seems advisable, in brief, that 
patients should do whatever is necessary to maintain the best possible 
general health, while restraining their activities within the limits set 
by their diet and tolerance. With a more hopeful general prognosis, 
it becomes highly important to guard patients against alcohol and 
drug habits; and especially as opium and other drugs are worthless 
or harmful, and alcohol as a means of adding calories is also inadvis- 
able, it is important that their widespread use in diabetic treatment 
be stopped. With other indulgences, such as tobacco, tea, and coffee, 
there are two opposite considerations. On the one hand, these articles 
in excess probably injure all persons, and even in moderation appar- 
ently injure some persons. On the other hand, the diabetic is denied 
so many enjoyments in diet that it is a pity to deprive him of any 
pleasures unnecessarily. Accordingly, the patients have been enjoined 

* Thomas, K., Arch. Physiol, 1910, 249-285. 



GENERAL PLAN OF TREATMENT 89 

to use such moderation in these respects as is advisable for normal 
persons. Smoking within careful limits has seemed very enjoyjtble 
to men long addicted to it. All habitual users of coffee have derived 
the utmost comfort from it, especially during fasting. From one to 
three cups a day has been the allowance, and decaffeinized coffee has 
been used if there was any suspicion of harm. In all other matters, 
the usual life of the patient should be altered just as little and just as 
much as demanded by the particular case. It will be seen that fre- 
quently in this series men have continued business, children have at- 
tended school, and everything possible has been done to keep patients 
contented and useful. Especially those with milder diabetes are able 
to pursue practically a normal existence with care only in diet, and 
this fact is one of the most hopeful elements in the prognosis and one 
of the greatest encouragements to fidelity in diet. Either mental or 
physical overstrain is injurious to such a degree as to be out of the 
question for the severest cases and inadvisable even for the milder 
ones. Healthful rest, short of ennui, is important. Exercise is dis- 
cussed in Chapter V. While reduction of weight and diet to a cer- 
tain point is known to be compatible with physical and mental 
efl&ciency, with more extreme diminution these are progressively im- 
paired, until in the severest cases emaciation and invahdism are 
chronic. Even in these worst cases, much depends on the individual 
disposition, and light emplojonent or amusement aids in keeping the 
mind off the subject of food. If it comes to a choice, neurasthenia is 
preferable to overfeeding. Finally, one of the most important points 
in the hygiene of diabetics is the avoidance of infections, either great 
or small. This need not contraindicate outdoor exercise in cold 
weather, which may be one means of building up resistance for pa- 
tients who can stand it. For some, however, it means avoiding 
crowds or any places where colds or influenza may be caught. For 
others, it means the removal of foci of chronic or recurrent infection, 
even at the risk involved in surgery. The best possible care of the 
teeth, skin, and body in general is advisable at all times, though the 
extreme susceptibility of diabetics to troubles from these sources is 
greatly diminished under proper diet. 



II. Treatment up to Cessation of Glycosuria in Simple Cases. 



Any fixedly prescribed routine is opposed by the necessity of indi- 
vidualizing treatment to suit the special needs of every case, and by 
the desirability of free play for the physician's individuality and ad- 
justment to environment. The basic principle of undernutrition 
being grasped, the application can be made in various ways. This 
period is occupied by the observation diet (if used) and the initial 
fast. 

A. The Observation Diet. 

All sorts of possibilities are of course open in the choice of an ob- 
servation diet. One conservative plan is to leave the patient for a 
short time on as nearly as possible the same diet he has been taking, 
to guard against the danger of any sudden change, especially in the 
form of carbohydrate reduction. In order to establish data for com- 
paring cases with one another and also with cases in the literature 
treated by older methods, the majority of patients in this series have 
been placed for a few days (2 to 5) on a diet somewhat as follows: 



Protein per 24 hrs. 


Carbohydrate per 24 hrs. 


Fat per 24 hrs. 


1.5 gm. per kilo. 


10 to 25 gm. 


Sufficient to bring total calories to 35 per 
kilo body weight. 



This is essentially the traditional "carbohydrate-free diet," for the 
low carbohydrate allowance is given only in the form of green vege- 
tables, such as have usually been included in diets of this description 
in the past. With close laboratory and clinical observation, no hesi- 
tation has been felt in placing patients abruptly on this diet; and 
even though this was done in some very severe cases, such as No. 8, 
the ability to control acidosis when necessary by fasting prevented any 
mishap. This plan was necessary for the accurate study of the earlier 
cases. Also, it frequently shortened the requisite period of fasting, 

90 



GENERAL PLAN OF TREATMENT 91 

when the previous diet had been grossly improper. In general, it is 
not therapeutically advisable, and was seldom used when the pa- 
tient's condition at entrance seemed dangerous. More recently, this 
observation period has been omitted, treatment has been begun im- 
mediately, and the severity of the diabetes has been judged by the 
subsequent progress and food tolerance. 

B. The Initial Fast. 

If diabetes is deficiency of the function of food assimilation, logi- 
cally the most effective method of relieving strain upon this function 
should consist in withholding food. The benefit of such relief should 
apply not only to glycosuria but also to acidosis, irrespective of 
whether the latter is wholly secondary to glycosuria or is partly a 
specific diabetic phenomenon; and the slight ketonuria developed by 
normal persons on fasting should not serve to confuse this expectation. 

With regard to the initial tests on dogs, it may be mentioned that 
irregularities in the glycosuria following total pancreatectomy are 
well known, and in particular the urine may become free from sugar 
just befort death from starvation or weakness; but the fatal diabetic 
cachexia is always present and freedom from glycosuria never avails 
to save the lives of such animals. Also, partially depancreatized dogs, 
of the type best suited for therapeutic experiments, in the severest 
stage continue to show glycosuria through the most prolonged fast- 
ing, up to death or the hopeless exhaustion just preceding death. It 
was a serious question whether the severest clinical cases are in a 
similarly hopeless state, or whether they still correspond to the type 
of dogs which can be freed from glycosuria by fasting and then kept 
symptom-free at a more or less reduced weight by suitable regulation 
of the total diet. Some encouragement was found in the results of 
the shorter therapeutic fasts employed by former writers, but there 
was nowhere in the literature any description of such a procedure as 
contemplated, or any information as to what might happen if a pa- 
tient with the worst type of diabetes were suddenly subjected to abso- 
lute fasting until sugar-free. Accordingly, as noted in the history 
of patient No. 1, the first attempt was made with considerable caution. 
It so happened that this patient, although of the type in which glyco- 



92 CHAPTER II 

suria and acidosis had formerly been viewed as hopeless, and though 
chosen as one in whom at least no great harm could be done, re- 
sponded with rather exceptional ease to this treatment, and both 
glycosuria and sjonptoms of impending coma quickly disappeared. 
If this first experience had concerned a case, such as frequently en- 
countered later in the series, requiring from a week to 10 days for 
sugar-freedom, it is a question whether courage would have held out; 
and if by any chance this first case had been one of the rare ones which 
develop fatal acidosis on fasting, the proposed treatment might have 
ended there. The first fact demonstrated was that even the severest 
cases of human diabetes almost invariably become free from glycosuria 
and as a rule also improve markedly as respects acidosis upon fasting. 

Regarding the practical carrying out of the initial fast in ordinary 
cases, the following details may be noted. 

Water. — It is advantageous on general principles that the total 
daily intake of fluids be at least 1500 to 2000 cc, and patients have 
therefore been encouraged to drink tap water or any kind of mineral 
or table water rather freely. In hot weather, cracked ice has some- 
times been rehshed. No limit is placed on the fluid intake if patients 
desire more than the above quantity. 

Alcohol. — The use of alcohol was one of the early precautions 
adopted to support strength during fasting. According to some earlier 
literature, it not only produced no glycosuria but also might diminish 
acidosis. In a number of cases, 50 to 350 cc. whisky or brandy 
were given daily, in small divided doses every hour or two, the limit 
for any individual being always short of producing subjective or ob- 
jective symptoms. A rather general misapprehension was created 
by the first papers pubhshed, as it was not clearly understood that 
the use of alcohol was not new but was adopted entirely from pre- 
vious writers, that it was used for cases with extreme weakness or for 
other special purposes, and that it was never a primary or essential 
feature of the treatment. Experience has tended to discredit it even 
for the purposes for which it was first employed. It is a decided com- 
fort during fasting to persons already habituated to its use. In other 
persons, especially women and children, it often excites discomfort 
or even nausea, and is therefore detrimental. It has an unmistakably 
bracing action in weak patients, but its real effect is probably more 



GENERAL PLAN OF TREATMENT 93 

harmful than beneficial. Soup and coffee are preferable in almost 
every case. 

Soup. — In the great majority of cases, clear meat soup has been 
allowed in quantities up to 600 cc. daily during fasting. The trivial 
quantities of protein contained are harmless, but even such can be 
avoided if desired by substituting beef extract. Soup is very com- 
forting, and the fluid and salts may be valuable. 

Coffee. — One to three cups of coffee or Kaffee Hag daily are pleasing 
and supporting to most fasting patients. It is not advisable to 
cultivate the coffee habit in children or other persons not addicted 
to it. 

Solids. — Three to six of the bran muffins described subsequently in 
this chapter have generally been allowed daily during fasting. They 
are of some use in diminishing the feeling of emptiness. Theoreti- 
cally, small quantities of thrice cooked vegetables might be permissi- 
ble in the milder cases, but have very seldom been used, because there 
is no use in trying to trick the appetite too far, and it is better for 
patients to learn to bear rigorous fast-days. 

Purgation. — The habitual constipation of most diabetics renders a 
cathartic advisable at the outset. With the use of bran, there is 
generally more natural tendency to defecation. On a prolonged fast 
with only fluid intake, the patient may safely go for a week or more 
with no bowel movement. There is no specific virtue in purgation. 

Edema. — ^As mentioned, water retention even to the point of visible 
edema is sometimes observed in fasting, especially in the more severe 
cases. It seems never to have been reported in normal persons on 
simple fasting, but only in connection with prolonged malnutrition 
and abnormal living. Diabetics vary in susceptibiUty, but the imme- 
diate cause of edema is usually the salt of the above ingesta, especially 
the soup. No harm has ever been observed from the fluid retention. 
The prevention or remedy consists in the restriction or exclusion of 
salt. 

Comfort and Strength. — Fasting, sometimes up to a month or more 
in duration, has been a well known practice for purposes of metabolic 
studies and sometimes for public exhibitions, and the subjects have 
retained physical and mental powers through these long periods and 
have denied any real suffering. Fasting has also been one of the com- 



94 CHAPTER n 

monest religious customs of numerous peoples and sects. On the other 
hand, the omission of a single meal is often felt as a great privation, 
and a few days' abstinence from food is viewed as something serious 
and alarming, not only by people in general but even by numerous 
physicians. The most profoundly emaciated and cachectic diabetic 
patients undergo even a 10 day fast with ease and safety. The re- 
fusal of a patient to undergo fasting is generally as much the fault 
of his physician as of himself, provided he is of a type who 
will faithfully carry out any kind of careful dietetic treatment. The 
first fast generally dispels the dread, and furthermore is valuable for 
discipline. 

As described in the histories, the fasting treatment has been applied 
to patients in all physical states, from those appearing in full health 
and strength to those seeming at the point of death from weakness and 
emaciation. The effect upon the immediate comfort has varied with 
individuals. Some patients have entered with nausea or vomiting 
which prevented eating; others rejoiced in quick relief from acidosis 
symptoms; others had been overfed till fasting was agreeable in itself. 
At the other extreme are the occasional patients who, whether in 
good or poor health and flesh, feel weak, uncomfortable, and depressed 
whenever they fast. In the intermediate position are the great ma- 
jority of patients, who find fasting more or less inconvenient but no 
serious hardship, and who carry on their usual activities or amuse 
themselves in various ways during either long or short fasts. As 
stated elsewhere, some very weak patients have unmistakably gained 
strength on fasting. More or less decline in strength is the rule. 
Even in the most extreme cases, no adults have died from weakness 
either during or within any short time after fasting to sugar-freedom. 
Two small children (cases Nos. 45 and 71) entered with such a com- 
bination of extreme diabetes, acidosis, and weakness that the choice 
between coma and starvation could not be avoided; and it is conceiv- 
able that such a dilemma may be possible in very rare adult patients. 
The use of levulose as a restorative in sudden collapse of strength is 
illustrated in cases Nos. 4 and 45. 

Laboratory Control. — ^Laboratory tests are qualitative and quanti- 
tative. So much information is derivable from the former that it is 
generally possible to carry through a fast successfully by their guid- 



GENERAL PLAN OF TREATMENT 95 

ance alone. The qualitative test for urinary sugar has been the key- 
stone of the plan, since fasting is terminated on the day after it 
becomes negative. Acidosis can also be judged fairly safely by the 
increase or diminution of the ferric chloride test of the urine and of the 
Rothera test applied to the blood plasma (Wishart),and by the acid or 
alkaline reaction of the urine; by simply noting the dosage of alkali 
required to turn the urine alkaline, the latter test acquires a quantita- 
tive significance Also, in default of accurate measurements of blood 
alkalinity, the test proposed by Yandell Henderson* should not be 
overlooked; namely, that normal persons can hold the breath 30 or 
40 seconds without specially deep preparatory inspiration, but that 
this period diminishes somewhat in proportion to the reduction of 
blood alkali. 

Of quantitative tests, that for blood sugar is of minor practical im- 
portance during the fast. Generally the blood sugar falls; sometimes 
it rises at first even when glycosuria is diminishing and the general 
condition improving; and in the rare cases where fasting results badly, 
the persistence or increase of hyperglycemia may be one significant 
feature; but other tests are more important danger signals. Also, 
the quantity of sugar excreted in the urine is of little practical im- 
portance in the great majority of cases, though persistence or increase 
of glycosuria gives warning of the failure of fasting, and likewise of 
the danger of coma even independently of direct acidosis tests. 

Quantitauve nitrogen determinations are of significance for the ra- 
pidity of protein destruction and the D : N ratio, which is an im- 
portant index of severity. Increase of the quantity of amino-acids in 
blood and urine also marks the severe cases. 

Possibly some significant behavior of the blood fat may later be 
found, but at present such analyses have no established value as a 
guide for treatment at this stage. In dogs it seems probable that 
fasting acidosis is sometimes accompanied by increased lipemia, but 
in human patients fasting generally produces no increased turbidity 
of the plasma. 

The essential danger that threatens during fasting is acidosis, there- 
fore the tests for it are preeminent. All analyses of the urine are un- 

* Henderson, Y., /. Am. Med. Assn., 1914, Ixiii, 318. 



96 CHAPTER n 

reliable. Very high excretion of acetone bodies is dangerous, but yet 
the progress may be favorable; while lower excretion may indicate 
either less acidosis or more dangerous retention. The urinary am- 
monia is governed not only by the degree of acidosis but also by 
other factors such as the total nitrogen output and the alkali dosage. 
The recently developed blood tests are the most convenient as well 
as the most trustworthy. The Van Slyke method' of determining 
the C02-combining power of the blood plasma has been used in the 
present series of cases, because of its combination of ease and accu- 
racy. Methods showing the carbon dioxide tension of the alveolar air° 
are simple and almost equally reliable. Those requiring the patient's 
cooperation encounter difficulty in coma or similar states, and even 
the bag or mask methods are subject to possible errors from circulatory 
or other causes. The air analyses are specially useful to those de- 
siring to avoid the taking of blood, but both physicians and patients 
should learn that blood ought to be taken for various analyses as a 
means of intelligent diabetic treatment. The hydrogen ion concen- 
tration of the blood, determined by either the gas-chain method, the 
oxyhemoglobin dissociation, or the more convenient procedure of Levy, 
Rowntree, and Marriott,' has recently attracted attention clinically as 
well as experimentally, but is not so early or delicate an indicator of 
danger as the CO2 capacity. Quantitative analyses for acetone bodies* 
in the blood may sometimes be of practical service. For example, if 
high and increasing, they may give warning of impending coma, even if 
this is not revealed by any of the above mentioned tests. On the 
other hand, the danger in different diabetic cases by no means runs 
parallel to the ketonemia, neither has any infallible index yet been 
derived from the relative proportions of /3-oxybutyric and acetoacetic 
acids. 

In summary, therefore, all laboratory tests are open to more or less 
fallacy. The more tests performed, the more easily and accurately 
can the condition be judged and needful measures instituted. If it 

6 Van Slyke, D. D., and CuUen, G. E., J. Biol. Chem., 1917, xxx, 289. 
^ Fridericia, L. S., Bed. klin. Woch., 1914, li, 1268. Marriott, W. M., J. Am. 
Med. Assn., 1916, Ixvi, 1594. 

' Levy, Rowntree, and Marriott, Arch. Int. Med., 1915, xvi, 389. 
* Van Slyke and Fitz, J. Biol. Chem., 1917, xxxii, 495. 



GENERAL PLAN OE TREATMENT 97 

comes to a question of the absolute minimum of laboratory work on 
which fasting can justifiably be conducted, the methods of choice are 
the Benedict qualitative sugar test for the urine and the Van Slyke 
determination of the bicarbonate reserve of the blood plasma, together 
with the nitroprusside reaction in the plasma. 



III. Emergencies and Complications. 

A long list of greater or lesser troubles associated with diabetes 
might be enumerated here. As mentioned in Chapter VII, the pres- 
ent experience indicates that these traditional complications, which 
have been the cause of so much suffering and fatality in diabetes, are 
for the most part avoidable under efficient treatment; and when al- 
ready present, it is beUeved that the best and quickest means of 
curing any of these or hindering their further advance lies in fasting 
followed by restriction of the total diet as described. A physiological 
condition which stands as a real complication in the management of 
diabetes is pregnancy. It was encountered in only one instance in 
this series, namely case No. 38, where it was associated with a hope- 
less complex of infections. JosUn's experience has proved that the 
formerly grave prognosis for both mother and child can now be much 
brighter; and unless deterred by eugenic considerations, the possi- 
bility exists for women with not too severe diabetes to go through 
pregnancy successfully. The essential requirement is the same 
thorough dietetic treatment as for other patients. By far the chief 
emergencies or complications, however, which are liable to be en- 
countered in undertaking the fasting treatment, are acidosis and 
infection. 

A. Acidosis. 

1. Definition. 

If the normal resting metabolism upon which calorimetric studies 
are based be accepted as a standard, acidosis may be broadly defined 
as any departure from this normal tending to turn the reaction of the 
body to acid. It may thus include all possible states of increased 
production or deficient destruction of acid, administration of acid, 
retention of acid, or deficient supply or abnormal loss of bases. The 
most important clinical type of acidosis is a ketosis; namely, the 
occurrence of abnormal quantities of the so called acetone bodies — 

98 



GENERAL PLAN OF TREATMENT 99 

whether due strictly to excessive formation or deficient utihzation is 
uncertain. Therefore, in accordance with Naunyn's dictum, acidosis 
is present in diabetes whenever an abnormal increase of acetone sub- 
stances is demonstrable in the urine or blood. Attempts to replace 
this metabohc or biological definition by purely chemical conceptions 
of alteration of reaction, derived from experiments in vitro, have 
thus far been scientifically fallacious, on grounds which need not be 
reviewed here, and clinically are open to the following objections: 
(a) these changes represent no independent phenomenon, but only 
some late stage of a process which should properly be regarded as a 
unit from beginning to end; (6) the striking abnormal production of 
acid in the protoplasm, perhaps up to 100 gm. of /3-oxybutyric acid 
daily, is the essential disorder to be defined, and the mere neutraliza- 
tion of the products by alkali cannot properly be regarded as abolish- 
ing this biological acidosis; on the contrary, the necessity of amimonia 
formation or alkah dosage to maintain neutral relations should in it- 
self be considered evidence of acidosis; (c) the therapeutic point of the 
whole matter is that attempts to treat by neutrahzation of products 
are often illusory and sometimes dangerous even as temporary meas- 
ures, and lead always to failure in the end, while successful treatment 
can only consist in stopping the abnormal acid production which is 
the essential disturbance. 

2. Fasting and Undernutrition Txeatment in Various Types. 

The ordinary acidosis of severe diabetes is no contraindication to 
beginning a fast, and, as already stated, typically diminishes pro- 
gressively during the fast. The more severe the acidosis, and the 
more imminent the impending coma, the more urgently is fasting de- 
manded, so that the patients of this series who have entered in the 
most dangerous condition have been placed immediately on strict 
fasting. The results have been favorable, as shown in Chapter VII. 

In the milder cases of diabetes, including those previously free from 
acidosis, some degree of ketonuria, generally shght, sometimes rather 
heavy, may develop during fasting, without danger or any need for 
changing the fasting program. Exceptionally, however, in cases in- 
herently either mild or severe, blind persistence in fasting may result 



100 CHAPTER II 

in dangerous or fatal acidosis, as happened in one case (No. 30) in the 
present series. This difficulty, though exceptional, is certain to be 
encountered if any considerable nimiber of cases are treated; and the 
fact that it had not formerly been known is one evidence of the 
newness of the fasting method. 

This atypical behavior may sometimes be expected in middle-aged 
or elderly patients, who have carried their diabetes for possibly 5 
to 15 years with little or no apparent harm, whose glycosuria may be 
heavy or moderate, whose acidosis may be chronic but slight, and 
whose bodily state may be that of good nutrition or slight obesity. 
Such a case may appear very promising for quick and gratifying re- 
sults. During the fast, glycosuria may persist or diminish; keto- 
nuria is generally qualitatively heavy, but quantitatively may not 
be great, especially if alkali is not given. What is seen clinically is 
first a vague malaise, often with headache or pains elsewhere, dizzi- 
ness, and increasing prostration. Nausea seems to be invariable, and 
the gravest stage is when vomiting is established. Though the con- 
dition is acidosis, the appearance is not that of t3^ical coma. 
Dyspnea may not be prominent, and the consciousness may be clear 
up to the last hours or minutes of lif^. The end comes with uncon- 
trollable vomiting and profound and rapidly progressive weakness. 

Treatment in this final stage offers little hope. Glucose or levulose, 
orally, rectally, subcutaneously, or intravenously, should theoretically 
be most important, provided the diabetes is inherently mild enough to 
permit any effective utilization. A few patients elsewhere are said 
actually to have been saved by such means. If food can be taken at 
all, whatever protein-carbohydirate diet promises to be best retained 
is indicated. The use of sodium bicarbonate is customary; it is prob- 
ably best given intravenously, possibly by rectum, to avoid nausea. 
If carbohydrate or protein as above described succeeds in arresting 
the underlying intoxication, it is possible that the cautious use of 
bicarbonate may guard against death from simple deficit of alkali 
and thus .may be a temporary assistance in tiding over the crisis. 
The traditional large doses of alkali are dangerous. If the other 
measures fail to arrest the underlying toxic process, alkali, in any 
dosage is useless, and the patient dies just as certainly whether the 
blood alkalinity is low or high. 



GENERAL PLAN OF TEEATMENT 101 

The essential treatment lies in prevention, and with simple care 
these unnecessary accidents can be avoided. For this purpose, Joslin 
has introduced a precautionary program, which, briefly, consists first 
in omitting fat from the diet, then gradually diminishing protein and 
finally carbohydrate, down to complete fasting unless glycosuria ceases 
before. This is opposite to the orthodox treatment of a few years ago, 
which started with a gradual reduction of carbohydrate. The plan 
is theoretically sound, embodying the same general principle of under- 
nutrition which underlies all this treatment. Besides the usual loss 
of a little time, there is an imaginable disadvantage in very rare cases, 
which might be controllable by immediate fasting but within a few 
days might be advanced past hope; also it is a possible question 
whether a threatening acidosis may ever be aggravated by food of 
any sort, even protein and carbohydrate. The only concrete ob- 
servation is in case No. 55 of this series, where it must be confessed 
that the diet which made trouble on November 5 did contain an 
appreciable quantity of fat. In favor of the gradual procedure are 
the following considerations: first, in Joslin's experience, which is 
larger than any other, dangers such as here suggested have not actu- 
ally been met; second, the duration of the initial fast is shortened; 
and third, the occurrence of fasting acidosis has been entirely pre- 
vented. This modification has therefore been widely adopted and 
will doubtless continue in extensive use. Though Joslin's own cases 
are studied by complete laboratory methods, the modified treatment 
becomes more important in proportion as laboratory control is lacking. 

As already stated, the method of immediate fasting has been em- 
ployed in the whole of the present series. Since the early experience 
(case No. 30) calling attention to the occasional danger, it has been a 
simple matter by combined clinical and chemical observation to avoid 
further mishaps. The practical management of dangerous cases of 
acidosis may be discussed according to the three classes into which 
they fall. 

(a) Typical Coma. — ^Patients in actual deep coma generally die. 
The considerable proportion of recoveries in this series shows that 
treatment is not entirely useless. With coma impending but not yet 
complete, death was the usual outcome under former methods, but 
under fasting treatment the usual outcome is recovery. It is be- 



102 CHAPTER II 

lieved that immediate fasting, with the adjuvants mentioned below, 
is the safest general rule for cases of threatened coma. Generally the 
improvement is quick, and may be evident within twenty-four hours 
or less. Sometimes the patient may appear more stuporous on the 
second day than on the first, and the blood alkalinity may be almost 
stationary or may even fall a little. In all the favorable cases seen, 
there has been unmistakable improvement by the third day. It is 
worth noting that cases of ordinary coma, coming on in the usual 
manner on any kind of diet, have never shown injury from fasting; 
i.e., fasting acidosis has not developed where the threatened coma was 
due to feeding. The patients whom inexperienced physicians are 
likely to be afraid to fast are the ones who usually need fasting most 
and who usually show the most striking benefits. 

(&) Fasting Acidosis. — ^As stated, occasional patients, in no imme- 
diate danger of coma on whatever diet they may be taking, react to 
fasting with an increase of acidosis, sometimes to dangerous degree. 
The reason for this pecuharity is unknown, and there is also no known 
way of foreteUing which cases will exhibit it. Examination of the 
case records in this series will show that neither the mildness or severity 
or duration of the diabetes, nor the initial degree of acidosis, nor the 
intensity or persistance of glycosuria, nor the store of reserve fat 
represented by obesity or emaciation, nor the supply of circulating 
fat as represented by lipemia, necessarily stands as a determining 
factor. The same patient at different times may behave oppositely. 
Thus, several cases in this series displayed more or less tendency to 
fasting acidosis at first, while at subsequent periods they reacted to 
fasting with the usual decrease of acidosis. The essential treatment 
for fasting acidosis is food; and the only known rule of procedure up 
to the present is if a patient develops acidosis on feeding to fast 
him, and if he develops acidosis on fasting to feed him. The kind of 
food seems to be of subordinate importance. Thus the fasting acido- 
sis symptoms of patient No. 35 ceased entirely on an orthodox protein- 
fat diet, which represents the surest means of producing acidosis in 
most patients. Nevertheless, it should not be considered that the 
choice of diet is immaterial. Fat is theoretically disadvantageous. 
Carbohydrate may be beneficial if the diabetes is not too severe, but 
should be closely lunited to avoid too great hyperglycemia and gly- 



GENERAL PLAN OF TREATMENT 103 

cosuria. Protein is on general principles the most valuable food, and 
either alone or with such carbohydrate as may seem advisable, it 
makes up a low caloric diet which both relieves fasting acidosis and 
at the same time continues the benefit of undernutrition. After a 
few days of feeding, a second fast is generally well borne, and both 
glycosuria and acidosis are brought under control as usual. After 
thorough and successful treatment, all patients become able to 
undergo fasting without danger from acidosis. 

(c) Indistinctly separated from the above two groups are the occa- 
sional examples of extraordinary intensity. Some cases of diabetes 
almost from the outset, and others after a longer or shorter course of 
ordinary symptoms, reach this degree characterized by maximal dex- 
trose-nitrogen ratios, enormous protein breakdown, high amino-acid 
values in blood and urine, and extremely threatening acidosis. Unless 
further improvement in the treatment is devised, probably a majority 
of such patients will continue to die, as did several in the literature, 
and patient No. 39 in the present series. Some of them apparently 
represent a degree of diabetes which is uncontrollable by fasting, 
perhaps because fasting is not sufficiently potent to check the rush of 
metabolism. There are three favorable considerations in regard to 
this condition: first, though famiHar in dogs, it is rare in human pa- 
tients; second, it is sometimes controllable by skillful treatment; 
and third, a distinction exists between intensity and severity, for 
if it is possible to weather the immediate storm of symptoms, these 
extremely intense cases sometimes turn out later to be less severe 
than anticipated. Thus, the patient of Geyelin and DuBois gained 
a tolerance running into hundreds of grams of carbohydrate, and the 
patient of Jonas and Pepper seemingly recovered from his diabetes 
altogether. In Chapter VIII it is shown that the distinction rests 
upon the apparently functional nature of the chief disturbance un- 
derl3dng the intense symptoms, while anatomic destruction of the 
islands of Langerhans, which is the fundamental basis of true severity, 
has not necessarily advanced very far in these cases. As regards 
acidosis, it may be assumed as a general principle that if fasting does 
not control glycosuria the result will be coma. These cases differ from 
those of group (b), which somehow react unfavorably to fasting irre- 
spective of the presence or absence of glycosuria. The fatal acidosis 



104 CHAPTER n 

from prolonged fasting in the present group seems to occur only be- 
cause of the persistence of high glycosuria. Successful treatment has 
consisted in replacing fasting by an undernutrition diet of carbo- 
hydrate or protein. Carbohydrate may be helpful for diuresis, but 
with a maximal D:N ratio its value otherwise is questionable. 
Protein offers theoretically the greatest advantages, in that it fur- 
nishes carbohydrate and urea for diuresis and ammonia for neutral- 
izing acids, and at the same time is the most important food for 
maintaining strength and protecting body nitrogen. Successful 
treatment with carbohydrate and protein is illustrated by the cases 
of Geyelin and DuBois and Jonas and Pepper above mentioned. 
Success with pure protein diet is illustrated by case No. 37 in this 
series. This boy had first entered the hospital with impending coma 
which had developed on a mixed diet and which cleared up smoothly 
on fasting. In a relapse 11 months later, he was readmitted with gly- 
cosuria which had resisted 8 days of fasting and acidosis which 
threatened early coma if fasting were continued. By a practically 
pure protein diet for 10 days, the acidosis and other symptoms were 
relieved, and then glycosuria was easily abolished by fasting. As 
mentioned, in some cases fasting, feeding, alkali, and all other measures 
are unavailing, and here death occurs from acidosis or exhaustion 
within a few days. Obviously, all cases of this group should be under 
the care of the most experienced specialist available. 

3. Adjuvant Measures and Remarks. 

(o) Emptying Alimentary Canal. — ^When it is known that food has 
been recently eaten, lavage of the stomach is advisable in impending 
coma, and if there is any doubt, it is a wise precautionary measure. 
Joslin makes it a routine for children with dangerous acidosis. It is 
also important to empty the intestine thoroughly by a combination 
of any vigorous purgative and high colonic irrigation. There may be 
some incidental benefit from absorption of saline solution if this is 
used for the colonic injections, or of. alkali if the irrigation is per- 
formed with sodimn bicarbonate solution. Case No. 25 illustrates 
the great difl&culty of securing adequate intestinal evacuation in some 
instances, and also its importance. 



GENERAL PLAN OF TREATMENT 105 

(b) Drugs. — Except in accidental emergencies, it is doubtful if drugs 
ever rescue patients from acidosis. Such an emergency is shown in 
case No. 11. This patient was not actually saved; but if there is 
cardiac and renal failure along with acidosis, it is evidently possible 
that life may be preserved by medicines which restore circulation and 
excretion. When any patient is sinking into. the stupor of ordinary 
coma or the weakness of fasting acidosis, there is always the incli- 
nation to stimulate heart, brain, and kidneys by such drugs as caf- 
feine and digitalis, if only in the hope of supporting strength until 
other measures have time to take effect. The liberal use of coffee, as 
illustrated in a few cases in this series, may be of some slight service. 
But whether employed early or late, drugs are probably never able to 
change the result in uncomplicated cases. • If a large dose of alkali is 
given intravenously, there is a possible question whether some circu- 
latory stimulant might be of value for guarding against the sudden 
death which sometimes follows within a few hours. 

(c) Sugars. — Glucose and levulose have received long and extensive 
trial as weapons against acidosis in the past. Their promise of use- 
fulness is greatest in fasting acidosis, at the stage when all ordinary 
food is vomited. They may then be given, preferably in 5 per cent 
solution, rectally, subcutaneously, or intravenously. For the latter 
purpose, a slow continuous infusion by some such device as that of 
Woodyatt' appears obviously best. For ordinary coma, sugar might 
have some value as a diuretic, and also for diminishing the formation 
of acetone bodies if it can be burned. But as a rule, the blood sugar 
is already undesirably high, and little if any sugar can be metab- 
olized. It is well known that the attempted sugar treatment of coma 
has in general been such a failure that it has been abandoned by the 
best authorities. Von Noorden^" found absolute fasting more effective 
than levulose, milk, or oatmeal for coma. Anything that aggravates 
the diabetes and delays the clearing up of glycosuria may possibly 
act injuriously also upon the acidosis. For these reasons it is be- 
lieved that as a rule sugar or carbohydrate should not be used for the 
treatment of ordinary cases of acidosis. 

' Woodyatt, /. Biol. Chew,., 1917, xxix, 355-365. 
'" von Noorden, C, Zuckerkrankheit, 1912, 388. 



106 CHAPTER n 

{d) Alcohol. — So far as observable empirically, alcohol has shown 
no specific value in connection with acidosis. Some experiments to be 
published later agree with the finding of Higgins, Peabody, and Fitz" 
that it tends rather to increase acidosis. One objectionable feature 
is its frequent nauseating effect. For these reasons, the use of 
alcohol is considered inadvisable even for weak patients with serious 
acidosis. 

(e) Salts. — The value of inorganic salts and the danger of extreme 
loss of salt have been emphasized especially by Joslin. Sodium 
chloride is valuable as a diuretic; also, its retention is associated with 
edema, and only one patient with edema in Joslin's experience has 
ever died in diabetic coma. Therefore sodium chloride may be ad- 
ministered by mouth in quantities up to 20 or 30 gin. daily unless 
prevented by nausea or other contraindication; physiological saline 
solution also is useful, by rectum, subcutaneously, or intravenously, 
for conveying salt as well as fluid. In case No. 1 and a few others, 
trial was made of giving also salts of potassium, calcium, and mag- 
nesium, with a view to physiological balance, but no apparent advan- 
tage has been found in this plan over the use of sodium salts alone. 
Soup is valuable partly for the salts it contains. 

(f) Fluids. — As already mentioned, the conduct of fasting with 
ordinary moderate acidosis calls for only moderate quaritities of 
hquids. On the other hand, the largest practicable fluid supply is 
one of the most essential matters in the treatment of threatened 
coma. Authorities from Rumpf to Joslin have recognized the 
danger of desiccation of the body, especially with the vomiting which 
occurs so frequently. The further use of fluids is to promote the 
freest possible diuresis. Joslin set the standard of 10 liters a day 
when possible. If the patient can drink and retain sufficient liquid, 
it need not be given in other ways. The patient should be persuaded 
to take water as much and as often as possible, either hot or cold, and 
free use should also be made of coffee, tea, soup, cracked ice, or what- 
ever else will aid in introducing fluid and perhaps also in preventing 
nausea. If drinking is insufficient — for example, if an adult with im- 
pending coma cannot retain 5 liters per day — recourse may be had to 

" Higgins, H. L., Peabody, F. W., and Fitz, R., /. Med. Research, 1916, xxxiv. 
263-272. 



GENERAL PLAN OF TREATMENT 107 

corresponding quantities of 0.85 per cent sodium chloride solution by 
rectum, subcutaneously, or intravenously. From 500 to 1000 cc. 
salt solution at a dose intravenously is considered by Joslin often 
preferable to alkali, because less dangerous. Here again the Wood- 
yatt injection apparatus might be advantageous. The reasons for 
the importance of keeping up copious diur-esis by fliiids are the fol- 
lowing. First, the possible concentration of acetone bodies in the 
urine is limited (the highest observed by Fitz was between 9 and 10 
gm. per liter); for this reason the excretion can often be multipHed 
by almost as much as the quantity of urine is multiplied, and large 
quantities of dangerous material thus removed. A high excretion, 
e.g. 50 gm. or more of total acetone bodies daily, is never possible ex- 
cept with abundant diuresis. Second, /3-oxybutyric and acetoacetic 
acids circulate in the blood only in the form of salts. They are partly 
eliminated as salts, but also to an important extent the kidney saves 
the base for the body and excretes the free acids. Through this saving 
of base by the acid-secreting power of the kidney, the administration 
of fluid is equivalent in some degree to the administration of alkali, 
without the special disadvantages or dangers of the latter.. . 

(g) Laboratory Guidance. — Mention has already been made of the 
various routine tests for acidosis, and preference expressed for the 
Van Slyke plasma bicarbonate method. More reliance can be 
placed upon the blood alkalinity, determined by this or by one 
of the less direct methods, than upon any other single feature of the 
condition, and without this information it is often impossible in 
critical cases to judge progress or direct treatment intelligently. 
With any serious degree of acidosis, estimation of the bicarbonate 
reserve should be made once daily. In acute danger, such analyses 
are sometimes demanded at frequent intervals, perhaps once every 4 
hours, to indicate whether the response to treatment is favorable or 
whether a change should be made. At this stage, the greatest service 
of this test is to give warning of an increase of acidosis on fasting, 
often before clinical symptoms make this evident, and in time to avert 
the danger by giving food. As an arbitrary ground plan for apply- 
ing the results of this test, the scheme in Table I may be suggested. 
Nevertheless, clinical judgment and experience are important in 
deciding whether unfavorable progress calls for a reversal of treatment 



108 



CHAPTER II 



or for more rigorous adherence to the same plan. There is ample 
evidence in the present series of cases that neither this nor any other 
single test can be followed blindly as an infallible guide. Irregularities 
are sometimes marked, even in absence of extraneous modif)dng factors. 
Thus, patient No. 63 showed the lowest CO2 capacity in the entire 
series (12.3 per cent), yet recovered promptly, whereas other patients 
died although their bicarbonate reserve was by no means so low. 
Patient No. 35 developed malaise, nausea, and drowsiness on fasting, 
and the observers were convinced that unless fed he would have died 
in the typical intoxication. The CO2 capacity was within normal 
limits even without alkah dosage. Probably it would have fallen 
at a later stage; but the significant facts are that the clinical symp- 
toms alone gave warning in time to permit effective treatment, that 

TABLE I. 



Degree of acidosis. 


Plasma COj. 


Further drop of COz pennitted before interrupting fast. 




vol. per cent 




— 


Above 53 . 


To 45 volume per cent. 


Mild. 


53-40 


Drop of 10 to 5 volume per cent. 


Moderately severe. 


40-31 


(t (c 3 <( 2 " " " 


Severe. 


Below 31. 


Fast interrupted in 6 to 12 hrs. unless CO2 rises 
with fasting and alkali. 



theintoxication symptoms increased when sodiumbicarbonateproduced 
an actual rise in the CO2 curve, and that feeding cleared up the sjonp- 
toms even though the CO2 capacity was slightly lower on certain subse- 
quent days than at the time of the intoxication. Such discrepancies and 
irregularities, spontaneous in origin, are much less numerous than those 
resulting from alkaU therapy. Thus in case No. 30, a typical ex- 
ample of acidosis with fatal result on fasting, the plasma bicarbonate 
was forced up within normal limits by alkali dosage while well marked 
intoxication was present, and the last reading, with severe and hope- 
less intoxication existing, was 45 per cent, which falls within the limits 
of "mild" acidosis according to the above table. Patient No. 45 
had before admission been kept saturated with huge doses of sodium 
bicarbonate. He' entered almost in coma, typical except, for absence 
of hyperpnea, notwithstanding the CO2 capacity of 73.5 volume 



GENERAL PLAN OF TREATMENT 109 

per cent in his plasma. In full coma on September 9, the CO2 ca- 
pacity was 84.9 volume per cent, i.e. abnormally high, and higher than 
on other occasions without coma. Patient No. 71 was received in 
coma with the usual low plasma bicarbonate of 22.1 per cent. On 
the subsequent days he remained intoxicated and delirious, even 
when the plasma bicarbonate was forced as high as 50.2 per cent, 
which is near the normal level for a boy of 9 years. Thereafter it 
was never below 38.8 per cent, and on the day of death in coma was 
48.5 per cent. Patients not in this series have also been seen, who 
died in coma notwithstanding normal CO2 capacity of the plasma. 
These facts cast no reflection upon the accuracy of the analytical 
method, but merely illustrate that dearth of alkali is not the sole nor 
essential feature of the condition. Fasting is sometimes beneficial 
even when the blood alkalinity falls somewhat; but in particular, a 
high alkalinity is no a:ssurance of safety in the presence of obvious 
chnical intoxication or a high and increasing concentration of acetone 
bodies in the blood. 

(h) Alkali Therapy. — This subject is partly discussed in connection 
with the results of the treatment of coma, in Chapter VII. The pos- 
sible benefits consist in relieving a dangerous dearth of alkali, and in 
facilitating the elimination of acetone bodies. The possible harm lies 
chiefly in the nausea which may result from oral administration and 
the sudden death which may follow within a few hours after excessive 
intravenous doses. It is conceivable that alkali may affect the toxic 
state for either good or ill in ways not now understood. Both bene- 
ficial and injurious effects are illustrated in the present series of 
cases. 

Close observation also shows that, whether the differences are sig- 
nificant or accidental, the condition called diabetic coma does not 
present a uniform picture. Aside from the rather atypical fasting 
form, there are differences in the symptoms which usher in coma. At 
one extreme are patients with extreme dyspnea, gasping so that 
speaking and swallowing are difficult, yet with consciousness perfectly 
clear until near the end. Such air-hunger is accounted for largely 
though not entirely by acid intoxication, and alkali may perhaps save 
life. Of patients of this tj^e, No. 63 was saved by alkali even after 
he had gone on into unconsciousness, when he might not have been 



no CHAPTER n 

saved by simple fastingj^ the dyspnea of No. 39 was somewhat re- 
lieved by alkali, but nevertheless she went on into stupor and died. 
At the other extreme are cases characterized chiefly by malaise, 
drunkenness, and drowsiness, with hyperpnea little marked; and these 
prodromal symptoms may also be relieved by alkali, sometimes with 
surprising promptness. The great majority of cases represent a 
mixture falling between these two extremes." 

The older clinical literature seems to prove that many patients with 
continuous ketonuria were saved from both dyspnea and intoxication 
for considerable periods by alkaU, and the onset of coma thus de- 
layed. In the treatment of actual coma, alkaH has been seldom 
successful, and the patients saved by it are few. Under all circum- 
stances, its effect is necessarily temporary and palliative. The fact 
is well known that the death rate from coma was not appreciably 
altered by the introduction of the alkali treatment. If death was 
somewhat deferred, the patient died subsequently in coma neverthe- 
less. Magnus-Levy recognized that this result could be prevented 
only by some method which would check the process of acetone body 
production. Fasting checks this process; accordingly the great ma- 
jority of cases of acidosis can be treated by this means alone, and 
alkali holds no more than a minor adjuvant position. Its use has 
seemed valuable under two conditions. The first is in combating a 
long and stubborn acidosis, as in patient No. 23, both for relieving 
malaise due to acidosis and for avoiding more serious danger. Ex- 
perience does not prove whether it is best given in smaller doses, 5 
or 10 gm. daily, for longer periods, or in larger doses on occasional 
days when demanded by clinical or laboratory indications. Such a 
need is rather rare, and the indiscriminate or routine use of alkali 
is not to be recommended. Particularly prolonged administration, 
of 2 weeks or more continuously, is probably best avoided, for fear of 
harm in some patients. The second use of alkali has been for com- 
bating coma in certain cases as already mentioned. Under all cir- 
cumstances, it must be understood that control of the metabolic 
condition by fasting or food is the essential means of treatment; 

"^^This was written before reading the closely similar observations of Cam- 
midge, Am. Med., 1916, xxii, 363-373, who suggests that one form is due to loss 
of blood alkaU, the other to loss of tissue alkali. 



GENERAL PLAN OF TREATMENT 



HI 



failure in this attempt must end fatally in spite of any dosage of 
alkali, and the crisis is not past until the production of acetone bodies 
is markedly and progressively diminishing. 

In any of the three types of acidosis above described, continuously 
high or increasing ketonemia and intoxication lead sooner or later 
to a condition where the further administration of alkali is ineffec- 
tual. The reason for the failure is unknown, because the real nature 
of the intoxication is unknown. The possible irregularities in the 
ketonemia and the alkaline reserve are indicated by observations of 
Fitz'^ upon three fatal cases of coma (Table II). 

TABLE II. 





1st observation 


, in early coma. 


Interval 
between 1st 

and 2nd 
observations. 


Sodium 
bicarbonate 
by mouth 
in interval. 


2nd observation shortly before 
death in coma. 


Case No. 


CO2 capacity 
of plasma. 


Total acetone 

bodies of plasma 

(as acetone) 

per 100 cc. 


CO2 capacity 
of plasma. 


Total acetone 

bodies of plasma 

(as acetone) 

per 100 cc. 


72 ■ 

71 


sol. per cent 
18.9 
14.0 
22.1 


mg. 

71.2 . 

54.5 
83.8 


35 hrs. 
8 " 
8 days 


gm. 



25 

72 


per cent 
26.7 
17.0 

48.5 


mg. 
127 

97.8 
192.5 



By reference to the history of case No. 71, it will further be seen 
that during 4 days before the final observation, the CO2 capacity 
of the plasma ranged from 38.8 to 50.2 per cent, and the total acetone 
of the plasma between 212.5 and 368.4 mg. per 100 cc. Also, there 
was no constant relation between plasma alkali and plasma acetone. 
These cases afford additional illustrations of increasing intoxication 
and death notwithstanding rising alkaline reserve of the plasma. 
Still other examples might be gathered from the literature to show 
that the intoxication is by no means in proportion to the concentration 
of total acetone in the plasma. Hence the failure of alkaU is not 
necessarily an insufficiency of diuresis resulting in retention of these 
acids or their salts. There is no evidence that alkali either increased 
or diminished the production or accumulation of acetone bodies at 
this stage. This point deserves further investigation. The sugges- 

'^ Fitz, R.. Acetone Bodies in the Blood in Diabetes, Tr. Assn. Am. Phys., 1917, 
xxxii, 155-158. 



112 CHAPTER n 

tion, especially of recent English authors," that the explanation hes 
in different relative proportions of acetoacetic and hydroxybutyric 
acids, the one being more toxic than the other, lacks proof at present. 
There is need of more clinical observations and animal experiments 
also on this question. In fact, nothing more than a descriptive status 
is really estabhshed even for the word "intoxication." Diabetic coma 
is a profound breakdown of metabolism. It may well be, in accord 
with Woodyatt's ideas, that the abnormality extends through the 
whole chain of intermediary compounds, that no one substance will 
be demonstrable in lethal quantity and toxicity, but that the general 
disorder of protoplasmic chemistry may be responsible for death. 
Alkali could necessarily have little influence here. Certainly the con- 
dition is complex. Ketonuria, ketonemia, lowered plasma alkalinity, 
and clinical symptoms are ordinarily associated in a relation regarded 
as t)^ical. The abnormahties of kidney function with severe acidosis 
are notorious; they presumably involve variable excretion of acids and 
bases; they necessarily upset any calculations based on normal renal 
activity; and they may explain more or less of the exceptional behavior 
noted. Aside from the occasional spontaneous variations, it is ob- 
viously possible to distort the usual relations by artificial alteration of 
one feature, for example raising the blood alkali by administration of 
alkali, without altering the underlying process or the clinical result. 
For practical purposes, sodium bicarbonate is the alkali of choice, 
on the basis of effectiveness and innocuousness. A salt of strongly 
alkahne reaction, such as sodium carbonate, deranges the stomach 
more readily, and its intravenous use involves greater danger of 
thrombosis in veins'^ or, in case of leakage, necrosis about them. 
Stronger alkalies must be changed immediately into sodium bicarbon- 
ate in the circulation, by chemical laws and because an actually alka- 
line reaction of the blood would be incompatible with Kfe. This fact 
does not necessarily conflict with Murlin's" observation of a differ- 
ence in the action of sodiimi carbonate and bicarbonate upon experi- 

1* Cf. Hurtley, W. H., Quart. J. Med., 1916, ix, 301-408. Kennaway, E. L. 
Biochem. J., 1914, viii, 355-365. 

" Cf. Umber, Deutsch. med. Woch., 1912, xxxviii, 1403. 

" Murlin, J. R., and Sweet, J. E., /. Biol. Chem., 1916-17, xxviii, 261-288. 
Murlin, J. R., and Graver, L. F., Ibid., 289-314. 



GENERAL PLAN OF TREATMENT 113 

mental animals; but no superiority of strong alkalies in the practical 
treatment of human cases has been established. Any special advan- 
tages in the use of other bases (potassium, calcium, magnesium) have 
also not as yet been demonstrated. 

Sodium bicarbonate can be given by the four usual routes. 

By Mouth. — This method is preferred when possible. The maxi- 
mar dosage is generally 2 or 3 gm. an hour or 5 gm. every 2 hours. 
Few patients can take 100 gm. per day, and none can take this for 
many days in succession. If the taste is objectionable, it is prob- 
ably best disguised by administering in carbonated water. The 
most serious objection to the oral method is the possible nausea, 
and the dosage should be regulated to avoid this. Diarrhea is also 
frequent. More or less edema, generally harmless, may result from large 
doses. Defective or sensitive kidneys may possibly suffer injury, and 
inhibition of diuresis is a possible serious consequence. On the whole, 
this method is the safest and with prudence seldom results in harm. 

By Rectum. — The well known drop method is the best. In deep 
coma, retention and absorption are generally poor. In a less extreme 
stage, this method may be the safest and most convenient substitute 
or supplement for oral administration. A mixture of equal parts of 
physiological saline and 4 per cent sodium bicarbonate solution (mak- 
ing a 2 per cent bicarbonate) was recently given thus to a boy of 12 
years for 4 days continuously, and as much as 35 gm. sodium bicar- 
bonate and corresponding quantities of fluid were thus introduced 
without the least difficulty or irritation. There is a possible question 
whether, if the large bowel is filled with injection fluid, there may be 
any effect on peristalsis higher up which will aggravate vomiting or 
interfere with dosage by stomach. Otherwise there is probably no 
objection to giving alkali by rectum. 

Intravenously. -^Th.e usual fluid for injection is 4 per cent sodium bi- 
carbonate in water or salt solution. Followers of Martin Fischer favor 
hypertonic solutions, for withdrawing water from the tissues and for 
promoting diuresis. Intravenous alkali injections, instead of being 
among the first measures employed, should be resorted to only 
reluctantly and on urgent necessity. The possible danger of the 
familiar practice of injecting a liter of 4 per cent bicarbonate solution 
has already been mentioned. The occasional sudden reviving effect 



114 CHAPTER n 

is probably due to a circulatory influence of the bicarbonate or the 
fluid or both. It is ahnost always temporary, and perhaps carries 
in itself the danger of later collapse. There are times when not 
enough alkali can be given by stomach or rectum to prevent a danger- 
ous fall in blood alkalinity. The intravenous method is then com- 
monly used, but the quantities are probably most safely limited to 
about 250 cc. for adults, repeated at intervals of several hours if neces- 
sary. Presimiably the Woodyatt apparatus for continuous imiform 
injection would be best of all. Intravenous alkali injections should be 
used to keep the blood alkaU from falling too dangerously low, rather 
than to try to maintain it at a normal level, but sometimes remark- 
ably large quantities are required even for the former purpose. The 
largest doses may be demanded especially in the severest intoxication, 
which is the very time when, owing to feeble circulation, the danger 
is greatest. 

Since boiling changes bicarbonate into the carbonate, solutions 
may be prepared in one of the following three ways: (1) by boiling the 
solution, and then passing sterile CO2 gas through it to change car- 
bonate back to bicarbonate, until a pink color is no longer obtained 
in samples tested with phenoIphthalein;i' (2) by making the solution 
without boiling, sterilizing it by filtration through porcelain; (3) by 
taking clean sodium bicarbonate, preferably from a freshly opened 
package of a chemically pure brand, with sterile apparatus into sterile 
water or salt solution, without further sterilization." This last and 
easiest method is safe enough for intravenous and perhaps even for 
subcutaneous use. Solid particles are removed by filtration through 
sterile cotton or filter paper if necessary. Solutions are wanned to 
body temperature before injection. 

Subcutaneously. — Magnus-Levy" called attention to the fact that 
sodium bicarbonate, as a neutral salt without marked irritating prop- 
erties, can be given subcutaneously. The method is relatively little 
employed, because of the fear of infecting or damaging the susceptible 
tissues of a diabetic, as well as producing pain or discomfort. One 
feature of usefulness was demonstrated in the twelve year old boy 

" Magnus-Levy, A., Ueber subkutane Infusionen von Mononatriumkarbonat, 
Therap. Monatsh., 1913, xxvii, 838-843. Also Joslin's text, 1917, 397. 



GENERAL PLAN OF TREATMENT 115 

above mentioned. On his last day of life, 35 gm. sodium bicarbonate 
given by rectum were only partly absorbed. 40 gm. given intraven- 
ously failed to check the fall of the alkaUne reserve. The patient 
was sinking into unconsciousness, with Kussmaul breathing and the 
full picture of typical diabetic coma; CO2 capacity of plasma 26.5 
volume per cent. A total of 90 gm. sodium bicarbonate in 4 per 
cent solution was given subcutaneously between 7 :30 p.m. and mid- 
night. The hyperpnea was considerably diminished; there was no 
perceptible influence upon consciousness or the general condition for 
either good or ill. The slow increase of intoxication continued as 
before. Death occurred at 1:40 a.m., and blood taken immediately 
after showed a plasma bicarbonate reading of 68.1 volume per cent. 
A few authors heretofore have opposed the acid intoxication hy- 
pothesis by reporting death in coma with alkaline urine. Inability 
to give enough alkali has been a prevalent excuse for failure. There 
is no objection to placing enough bicarbonate beneath the skin to 
give the patient the benefit of any desired level of alkalinity; and 
with the aid of the recent improved methods of estimating the alka- 
line reserve, it is possible for any follower of the acid intoxication doc- 
trine to convince himself that the patient's blood alkali can be kept 
at a fully normal level, but he dies in deep coma nevertheless. 

B. Infectious and Surgical Complications and Emergencies. 

The methods employed in managing cases of this group are shown 
in the individual histories, and the collective results are presented 
in Chapter VII. The experience, though favorable on the whole, is 
so limited that discussion of the treatment must be based largely on 
the literature and on general principles. For the older literature, 
reference may be made to text-books and the papers of Umber,i' 
Kaposi,!' Kraus,^" and Karewski;^! and for developments under the 
newer dietetic methods, to JosUn's text and Strouse's^^ paper. Com- 

^* Umber, Deutsch. med. Woch., 1912, xxxviii, 1401-1403, 1433-1434. 
" Kaposi, H., Ergebn. Chir., 1913, vi, 52-75 (128 references to literature). 
^^ Kraus, F., Deutsch. med. Woch., 1914, xl, 3-8 (with statements by Naunyn, 
von Noorden, and Minkowski). 
^iKarewski, F., Deutsch. med. Woch., 1914, xl, 8-13. 
22 Strouse, S., Med. Clin. Chicago, 1916, ii, 37-52. 



116 CHAPTER n 

plete discussion of surgical complications, like complete treatment of a 
patient, demands the collaboration of physician and surgeon. The 
present brief suggestions will omit statistics, most surgical details 
and finer classifications, and will be limited to general outHnes of 
practical procedure. 

Certain broad dicta may be taken directly from former authors. 
First, every patient coming for treatment of any medical or surgical 
ailment should have the urine tested for sugar, whether diabetes is 
suspected or not. There is ample proof that this admonition is far 
from superfluous even today. Even with a negative test, Kaposi 
urges strict inquiry for diabetes in the family or past history, and 
attention to present or past obesity, suppurations, or other sus- 
picious indications. Second, mildness of the diabetes and slightness 
of the complication or operation promise the best outcome and the 
least contraindication to surgical measures; but mild diabetes may 
turn suddenly severe with a complication or shock, and a complica- 
tion may be aggravated by diabetes, so that unnecessary interference 
should be avoided in the presence of any active symptoms, and the 
prognosis should always be guarded. The more threatening the 
comphcation and the more critical the necessity of surgical inter- 
vention, the less is diabetes regarded as a contraindication. Third, 
the special dangers threatening the diabetic are peculiar susceptibility 
to infection, subnormal healing and repairing power, and acidosis. 
The last causes most deaths. The first two are largely overcome by 
aseptic and operative care. Fourth, the better the dietetic prepara- 
tion, the less the danger. Since acidosis is the chief peril, the best 
preparation will include a maximum assimilation of carbohydrate; 
therefore formerly ap oatmeal period was recommended (von Noor- 
den, Addis, and others).^' Fifth, the surgical technique of an emer- 
gency operation should be the simplest yet most effective possible, 
avoiding shock, traumatism or long anemia of the parts, elaborate- 
ness, and anything tending to lengthen the time of operation or 
dispose to subsequent sloughing or infection. Sixth, local or spinal 
anesthesia is considered safest from the standpoint of acidosis. 
Proper general anesthesia is usually well borne by well prepared 

23 Addis, T., J. Am. Med. Assn., 1915, Ixiv, 1130-1134. 



GENERAL PLAN OF TREATMENT 117 

patients. It should be as brief as possible. Psychic as well as 
physical distress should be guarded against. The anesthetic of 
choice is nitrous oxide and oxygen. Ether is more dangerous. 
Chloroform should never be used for diabetics. Seventh, postopera- 
tive care includes on the one hand the most skilled dieting, aiming 
particularly at carbohydrate assimilation, and on the other hand sur- 
gical precautions, such as exercise and other measures favoring cir- 
culation and general hygiene, and avoidance of tight dressings. 
Eighth, fatal coma or other disaster may occur from any sort of 
operation, in any grade of diabetes, after any form of preparation, 
any kind of anesthetic, and any postoperative care (Naunyn, Karew- 
ski, and others). Ninth, operative relief from tumors or other 
troubles sometimes has a beneficial influence upon the diabetes 
(Eising and others).^ Tenth, the use of alkali stands on about the 
same basis as in uncomplicated cases. The frequent occurrence of 
acidosis with operation or anesthesia in non-diabetics has been brought 
into some prominence of late (Crile,^^ Bradner and Reimann,*^ Bum- 
ham,*' Lincoln,^' Morriss,*' and others). The recent work of Hen- 
derson and Haggard^" indicates that the lowering of the carbon 
dioxide capacity of the plasma does not represent a true acidosis. 
Accordingly, only the acetone body production can here be regarded 
as evidence of acidosis. The treatment has consisted in preliminary 
carbohydrate diet, and, in emergency, glucose and sodium bicarbon- 
ate, alone or separately, orally, rectally, subcutaneously, or intra- 
venously. The glucose is unquestionably the more important for a 
non-diabetic. The value of alkali has been questioned. Naunyn 
strongly advocated saturating every diabetic with sodium bicarbon- 
ate before operation, and he has had the largest following. Undoubt- 
edly the blood alkahnity can be raised by alkali dosage, but there is 
the open question whether artificially raising the blood alkalinity is 

2* Eising, E. H., /. Am. Med. Assn., 1914, Ixii, 1244-1245. 
" Crile, G. W., Ann. Surg., 1915, Ixii, 257-»-263; ^w. Med., 1916, xxii, 447^51. 
2^ Bradner, M. R., and Reimann, S. P., Am. J. Med. Sc, 1915, cl, 727-733. 
"Burnham, A. C, Am. Med., 1916, xxii, 438-441. 

28 Lincoln, W. A., Ann. Surg., 1917, Ixv, 135-141. 

29 Morriss, W. H., /. Am. Med. Assn., 1917, Ixviii, 1391-1394. 

5" Henderson, Y., and Haggard, H. W., J. Biol. Chem., 1918, xxxiii, 333-371. 



118 CHAPTER II 

necessarily synon37inous with benefiting the patient. Alkali has not 
prevented the high mortahty from postoperative acidosis in the past, 
Strouse has had good results in operations with alkali, and Joslin 
in operations without alkaU. The practitioner's choice in individual 
cases will be governed by his attitude on the general subject. 

Contrary to past practice, alcohol is at present not used in this 
hospital as a food at any stage in diabetic complications or the 
acidosis accompanying them. 

Authors have divided complications into those for which the diabetes 
is wholly or partly responsible, and those independent of the diabetes. 
Therapeutic measures are sometimes influenced by theories as to the 
reason why diabetics are subject to so many characteristic compli- 
cations and so lacking in resistance to damage of all kinds. Notions 
that excess of sugar directly injures tissues or provides a favorable 
medium for bacteria have been sufficiently discredited. It is also 
important to emphasize that thougli malnutrition predisposes to in- 
fection, the susceptibility of diabetics is something special and 
peculiar, since hunian beings or animals suffering from other condi- 
tions involving equal or greater inanition and cachexia are not 
afflicted in this manner or degree. As formerly pointed out," one 
general conception of diabetes is apphcable also to all complications. 
The present treatment is built upon the idea, supported by consid- 
erable evidence in addition to the treatment, that diabetes is weak- 
ness of the general nutritive function, including both cataboUsm and 
anaboHsm. It is thoroughly in line with this poin^ of view that every 
part of the diabetic body should manifest diminished power of main- 
taining normal function, of repairing the natural wear and tear, of 
healing wounds, and of resisting infectious invasions. Not only the 
grosser complications, but also retinitis, cataract, arteriosclerosis, 
neuritis, asthenia out of proportion to loss of flesh, and the multitude 
of other disorders listed in classical text-books, accord with this con- 
ception. Since the trouble is due to deficiency not of nutritive ma- 
terials but of the nutritive function, relief should be expected from 
strengthening this function, even at the price of dimmished food supply 
and body weight. Experience indicates that this result actually 

«i Men, Am. J. Med. Sc, 1917, cliii, 313-371. 



GENERAL PLAN OF TREATMENT 119 

follows, and that there should be no hesitation to impose rational un- 
dernutrition for the purpose of raising resistance. 

Complications and operations fall for practical management into 
those with which there is opportunity for preparation, and those 
affording no opportunity for preparation. 

1. When There is Time for Preparation. 

(a) Prophylaxis. — ^Just as the food tolerance is never fully restored 
in typical diabetes, so also the Resistance is probably never entirely 
normal. It is possible, for example, that no dietetic treatment will 
ever bring the resistance to tuberculosis quite to normal, and that the 
incidence of this disease will accordingly always be higher among 
diabetics than among the general population. Also, if an infection 
does gain lodgment, there is always the danger that diabetes will be 
made worse and that resistance will collapse correspondingly. On 
the other hand, resistance is probably highest when a diabetic is 
kept as nearly as possible like a correspondingly undernourished 
non-diabetic. Reduction of diet to something like the Chittenden 
standard has never been shown to cause serious lowering of resist- 
ance. Below this scale, freedom from symptoms necessitates emacia- 
tion and weakness in proportion to the severity of the diabetes; but 
it has repeatedly been pointed out that feeding beyond the tolerance 
gives only a temporary and dearly bought benefit to weight and 
strength, and it seems evident that such an attempt actually lowers 
resistance at all stages. Three points of prophylactic advantage from 
efficient dietetic treatment can be set down as facts. First, the long 
list of complications which have been the chief torment of diabetic 
patients in the past are largely prevented; a pimple does not de- 
velop into a carbuncle; an abraded toe heals instead of becoming 
gangrenous, etc. Second, the aggravating influence of complications 
upon, diabetes is thus either avoided or reduced to a minimum. 
Certain cases in the present series show the occasional possibility of 
attaining the ideal that a patient shall pass through a crisis of in- 
fection or operation without developing either glycosuria or acidosis; 
and in a larger proportion it is possible to avert acute death and also 
guard against any lasting injury to the diabetes. Third, health and 



120 CHAPTER II 

resistance are maintained either indefinitely or for the longest pos- 
sible time, whereas overfeeding entails progressive decline in all re- 
spects and corresponding liability to and damage from complications. 

(&) Preparation for Emergency. — This is generally synonymous with 
preparation for operation. The time available naturally varies with 
the surgical condition, but something like a tumor or a quiescent 
appendix may permit all necessary leisure and care. Active diabetes 
is first controlled in the usual manner. A carbohydrate period is 
important thereafter; and if acetone is persistent, it is probably best 
to continue the highest possible carbohydrate diet without fat until 
the Rothera reaction is negative if possible. The blood sugar and 
all other tests should also be brought to normal if circumstances per- 
mit. Meantime, protein will lower carbohydrate assimilation and 
may tend to prolong acidosis, but will support strength better than 
any other food. It may be called an ideal preparation which sends 
a patient to operation after a fat-free diet of 1.5 gm. protein per 
kilogram of weight and the highest feasible carbohydrate ration, with 
all laboratory tests normal. In case of sudden damage of assimila- 
tion from operation or anesthesia, this arrangement insures the 
greatest possible liability to glycosuria, which is generally easy to 
control, and the least possible liability to acidosis, which is the chief 
danger. Joslin and Strouse give examples of preparation along these 
lines. The latter, for example, prepared a woman with a fat-poor 
diet of eggs and 85 gm. carbohydrate, so that the urine was free from 
sugar for 15 days and from acetone for 5 days before operation. A 
combined hysterectomy, right salpingectomy, and oophorectomy, 
under nitrous oxide preceded by morphine and atropine, was then borne 
without incident other than one day of glycosuria. While diabetes 
necessarily involves operative danger, it is believed that these prin- 
ciples offer the best chance of safety. 

(c) Treatment with Subacute or Chronic Complications. — ^As men- 
tioned elsewhere, some complications, such as nephritis, require no 
departure from ordinary management. Others, such as infections 
or pregnancy, have interrelations with diabetes which are important 
in influencing both conditions. On the whole, the most serious 
medical complication is tuberculosis, and especially the conflict is 
sharp here between the overfeeding customary for one disease and the 



GENERAL PLAN OF TREATMENT 121 

underfeeding demanded by the other. Severe tuberculosis with 
severe diabetes makes an inevitably fatal prognosis. When either 
disease is mild, the chance is a little better but by no means good. 
When both are mild, treatment is more hopeful. A number of 
patients imder observation by recognized tuberculosis specialists 
have improved strikingly when taken off the traditional high diet 
and placed on a lower diet which abolished their diabetic symptoms. 
It is believed that this plan, with the usual fresh air and other 
measures, promises the best results with this combination. 

This belief is corroborated by the experience with surgical compli- 
cations, which proves plainly that tissue vitality and resistance to in- 
fection are built up by treatment which controls the diabetes. The 
most numerous class of surgical troubles are furunculosis and gan- 
grene. The best local treatment of both is palliative and conserva- 
tive. Surgical authorities seem to agree that incision of boils should 
be avoided, unless absolutely demanded by spreading infection or 
toxic absorption. Gangrene has been the occasion for multitudes 
of needless operations and deaths in the past. Together with cata- 
ract, retinitis, neuritis, and less numerous ills, it furnishes the strong- 
est reason for treating diabetes in the elderly as carefully as in the 
young; for notwithstanding the part attributed to arteriosclerosis or 
other causes, efficient dietetic treatment prevents such troubles almost 
without exception. Stetten and Lambert and Foster,'^ and others have 
proved the advisability of treating gangrene conservatively when pos- 
sible, with diet, measures to improve circulation, and simple local 
care. Even tissues appearing dead may revive to surprising degree. 
-A line of demarcation becomes established, and operation is either 
avoided or reduced to a minimum. It is bad advice to operate early 
and high, where the tissues and vessels are sound; and patients should 
not be operated on without dietetic preparation. The only indications 
for abandoning expectant treatment and operating promptly are ad- 
vancing infection or fever and intoxication, not checked by other 
measures and threatening danger either in themselves or in their 
influence upon the diabetes. Here the treatment demanded is that 

=2 Stetten, D. W., /. Am. Med. Assn., 1913, Ix, 1126-1133. Lambert, A. V. 
S., and Foster, N. B., Ann. Surg., 1914, lix, 176-185. 



122 CHAPTER n 

for an emergency, as discussed below. Otherwise, even if operation is 
later necessary, the longest possible time is afforded for preparation. 
Death from amputation should then nearly always be avoidable. 
The worst result recorded after such preparation is that of Baldwin,^' 
whose patient's urine quickly became free from sugar and acetone, 
and amputation under ether 3 weeks later was followed by death in 
coma within 2 days. Owing to lack of details, it is not possible to 
judge the fitness of the preparatory diet. Though such cases are 
generally rather mild, yet there is always the possibility of genuinely 
severe diabetes in an old person, or of continuous injury of assimila- 
tion by a chronic infection, so that either early or late operation 
may end in disaster. Complete laboratory tests are generally a reli- 
able means of judging whether operation is safe or not. 

2. When There Is Little or No Time for Preparation. 

The most dangerous emergencies are the cases suddenly presenting 
themselves with serious infection coupled with intense diabetic symp- 
toms. Some of the examples of exaggerated nitrogen loss, maximal 
D : N ratios, and uncontrollable acidosis belong in this class; e.g., 
Joslin's^* case No. 513. As the diabetes makes the infection worse 
and the infection makes the diabetes worse, it is frequently impossible 
to break the vicious circle, and a large proportion of such patients die. 
There probably is no constant rule of diet except to exclude fat. On 
the one hand, these patients are specially subject to fasting acidosis, 
so that feeding with carbohydrate or protein, either or both, may be 
necessary, perhaps for a majority. On the other hand, if past experi- 
ence indicates correctly that ordinary coma responds better to fast- 
ing than to carbohydrate, there is a chance that the same may be 
true of some cases with infection, and that control of the diabetes by 
the quickest and most radical means possible may be the one hope of 
saving life. 

As with uncomplicated cases, the plan in this hospital with infec- 
tions has been to impose immediate fasting and then depend upon 
clinical and laboratory indications for guidance. Chapter VII and the 

'« Baldwin, J. F., Am. J. Surg., 1916, xxx, 65. 

^* Joslin, E. P., Treatment of Diabetes Mellitus, 2nd edition, 1917, p. 353 fi. 



GENERAL PLAN OF TREATMENT 123 

case histories show the collective and individual experiences and re- 
sults. Medical emergencies, even of such magnitude as lobar pneu- 
monia, have for the most part been met successfully. Fasting has 
benefited some patients, while others have done well on low carbo- 
hydrate-protein diets. It is believed that the results on either plan 
are more favorable than are possible under any method based on the 
fallacy of overfeeding for the sake of strength. 

Surgical complications offer one more element of hope if the sur- 
gical treatment can succeed. The decision between radical and 
conservative measures is often most difl&cult and doubtful. On the 
one hand, dietetic control may revolutionize the surgical state and 
the infection may come quickly to a standstill, when operation might 
be fatal. Thus the life of the carbuncle patient No. 27 was probably 
saved by immediate fasting. On the other hand, with mistaken 
delay either the diabetes or the surgical condition may quickly be- 
come hopeless, and what is demanded is the most prompt and radical 
surgical intervention. Strouse gives an example of success due to 
right judgment. A pregnant diabetic woman with threatening 
acidosis was placed first on a low vegetable diet, but progressed rap- 
idly toward coma. Accordingly Caesarean section was performed 
under morphine and local anesthesia. Acidosis remained high for 2 
days, then cleared rapidly, and the patient was soon out of danger. 
The results of radically terminating a complication are apt to be 
most brilliant when, as in this case, the diabetes is inherently mild 
and is only stirred to intensity by the complication or by wrong diet. 
Both complications and operations are extremely dangerous in severe 
cases with flagrant symptoms. As the Carrel-Dakin method has 
been so widely adopted by surgeons, it is only necessary to mention 
the great importance of effective wound sterilization, not only for 
saving gangrenous limbs, but also in carbuncles or other surgical in- 
fections, to put an end to toxic absorption with the least possible 
shock or delay. With advancing sepsis, a quick amputation of a 
limb or removal of an appendix or other focus, even in the presence 
of threatening acidosis, may save life in a minority of cases. 

Postoperative care is adjusted to meet conditions. A well prepared 
patient, coming through operation symptom-free, may have his diet 
built up as in absence of comphcations, first with carbohydrate, then 



124 CHAPTER n 

with protein, finally with fat. In the presence of an emergency, the 
usual choice must be made between fasting and feeding for acidosis, 
following careful clinical and laboratory observations rather than any 
fixed rule. Nutrition and reparative power, emphasized by Jopson,'* 
are doubtless best served by protein as usual. While acidosis is the 
chief danger, absence of glycosuria should be maintained or achieved 
as early as possible, even at the price of lowered nutrition. 

All cases of this entire group demand the constant combined watch- 
fulness of the best surgeon and the best diabetic specialist available. 
With this cooperation Joslin's statistics show the favorable results 
obtainable in some of the most desperate cases. 

5" Jopson, J. H., Tr. College Phys. Philadelphia, 1916, xxxviii, 255-257. 



IV. Treatment Following Cessation of Glycosuria. 

Here are to be considered (A) the carbohydrate tolerance test; 
(B) the maintenance diet; (C) the period of observation and instruc- 
tion; and (D) the period of after-care. 

A. Carbohydrate Tolerance Test. 

After a patient becomes free from glycosuria, his fast is continued at 
least one day longer, so as to assure at least 24 hours of complete 
sugar-freedom before giving food. This plan also is based upon the 
idea of resting the weakened function. In mild cases, it is permissible 
to start the test when the patient is sugar-free, even without fasting. 
In severe cases with h3^erglycemia a fast-day usually precedes a 
carbohydrate test, even though glycosuria is already absent. In the 
severest cases of all, when the patient is extremely weak and the tol- 
erance is known to be trivial, the carbohydrate period is sometimes 
omitted and a period of gradually increasing protein substituted. It 
may be rather important to judge the severity correctly in this re- 
spect. Appearances may deceive the inexperienced, so that the 
benefits of the carbohydrate period are unnecessarily sacrificed in a 
patient actually possessing considerable reserve strength and toler- 
ance. On the other hand, with genuinely extreme weakness there is 
the possibihty of a fatal collapse of strength on the low vegetable 
ration, which would be prevented by protein. This danger is really 
serious only in children, because the collapse may come suddenly. 
Adults weaken so gradually that there is plenty of opportunity to 
avert collapse by substituting a low calory protein diet. 

The standard program of the carbohydrate test has been to give 
10 gm. carbohydrate the first day, and increase by 10 gm. daily until 
the limit is reached. The first trace of glycosuria does not neces- 
sarily represent the limit. When the first glycosuria appears, the 
practice has been to repeat on the following day the same quantity 
of carbohydrate which caused glycosuria. If the glycosuria disap- 

125 



126 CHAPTER n 

pears, the regular increase of 10 gm. daily then continues, and occa- 
sionally the true tolerance is found to be several times the quantity 
on which the first accidental trace of glycosuria appeared. When 
glycosuria occurs on two successive days with a certain intake, the 
tolerance is considered to be 10 gm. less than this; i.e., the highest 
quantity taken without glycosuria is regarded as the tolerance. 

The test is ordinarily carried out with green vegetables, for pur- 
poses of uniformity, and because they are the most bulky and there- 
fore most appreciated form of carbohydrate. The benefit of salts, 
vitamines, etc., in vegetables is a possible accessory advantage. On 
the first days, the hungry patient is naturally best pleased with the 
vegetables lowest in carbohydrate, which afford the greatest bulk. 
If the tolerance is high, the bulk soon becomes excessive. As far as 
possible, the patient's wishes are allowed to determine the choice of 
vegetables. While the approxinaate grouping into classes of 5 per cent, 
10 per cent, 15 per cent, etc., is a convenient guide in selection, it is 
necessary especially in severe cases to reckon the carbohydrate of 
each vegetable as accurately as possible from the standard tables, if 
the test is to be at all exact. With a high tolerance, the lower class 
vegetables are gradually replaced by those of higher carbohydrate 
content, until finally, with the highest tolerance, bread and cereals 
may be reached, though preference is given to potatoes and garden 
vegetables as long as possible, in order that absorbable protein may 
interfere as little as possible with the pure carbohydrate tolerance. 
Fruits are also permitted during the carbohydrate test, beginning 
generally with grapefruit in the earlier stages and advancing to those 
richer in carbohydrate. The fruit never represents more than a 
rather low fraction of the total carbohydrate intake, and with this 
arrangement the fruit sugar has seemed to make no important dif- 
ference as compared with starch in fixing the tolerance. 

Modifications of the standard plan are used chiefly to suit var3dng 
degrees of severity. It will be observed that the scheme outlined is 
particularly adapted to severe cases with low tolerance. If the tol- 
erance were 300 gm., an increase of 10 gm. per day would require a 
month for carrying out the test. The feasibility of prolonged vege- 
table diets is illustrated by cases Nos. 1 and 3, but they have no 
special virtue beyond the low calories, and exaggerated length of a car- 



GENERAL PLAN OF TREATMENT 127 

bohydrate test is generally undesirable. For this reason the increase 
in the milder cases is more than 10 gm. per day, sometimes as high 
as SO gm. per day. Two points are to be borne in mind in regard to 
such modifications. First, the tolerance determined by a rapid test 
is by no means strictly comparable to that found in a slow test in the 
same or another patient, inasmuch as the slower increase, by more 
prolonged undernutrition, builds up a definitely higher assimilation. 
Second, too short a test sacrifices much of the benefit, and a week or 
two if possible is profitably spent as a carbohydrate period. 

The purposes served by the test are diagnostic and therapeutic. 
Therefore it is repeated at 6 months or other intervals, as may seem 
convenient or desirable. 

Diagnostic. — ^First, the carbohydrate test serves as a basis for 
reckoning the subsequent carbohydrate allowance. The assimila- 
tion is considerably higher for carbohydrate taken alone than in a 
mixed diet, but the test gives a standard basis of reckoning. Second, 
the use of a uniform test permits comparisons between patients and 
between the same patient at different times, for judging both the 
severity of the case and the progress under treatment. 

Therapeutic. — ^First, most patients at the end of their fast have 
more or less acidosis. The vegetable period, which enables the 
highest possible assimilation of carbohydrate, is for this reason the 
quickest and most effective means of relieving acidosis. Ketonuria 
diminishes, and the. plasma bicarbonate rises without alkali dosage. 
Individual peculiarities regarding acidosis may be indicated by the 
varying stubbornness with which it resists carbohydrate ingestion. 
Second, there is important benefit in the undernutrition, which at 
first is almost like fasting. 

B. The Maintenance Diet. 

When the limit of tolerance has been reached in the carbohydrate 
test, a single fast-day is given to clear up glycosuria. Then (or im- 
mediately after the initial fast, if for any reason the carbohydrate 
period is omitted) the building up of a maintenance diet is begun. A 
fuU diet is not begun suddenly, for fear of bringing back symptoms. 
As may be seen in the case histories, scarcely any two cases have 



128 CHAPTER n 

been managed identically; the regime has been individualized to suit 
individual needs. With acidosis, carbohydrate is kept as liberal as 
possible. For weakness, protein is raised rather rapidly to 1.5 or at 
least 1 gm. per kilogram of body weight. Fat is added last, the 
addition is made slowly, and the final allowance is kept within the 
tolerance as nearly as this can be determined. Under the special 
conditions, the fat ration is what essentially determines the body 
weight, but the latter has been allowed to fall until a maintenance 
diet can be assimilated without obvious diabetic s}anptoms. 

A few cases in this series have been of a grade of severity indicated 
by the fact that, after cessation, glycosuria would return when the 
diet consisted solely of a few hundred grams of thrice cooked vegetables 
on certain days or of six or less eggs on other days. With such a 
trivial food tolerance, the diet is best limited to the small quantity 
of protein which can be taken without glycosuria, until the assimila* 
tion improves. For the most part, however, mixed diets have been 
given following the carbohydrate test, the increase being preferably 
limited to one class of food at a time, so as to observe the respective 
effects of the addition of carbohydrate, protein, or fat. The prin- 
ciples of the dietary plan were so clearly stated by Taylor'^ that 
his remarks are worth quoting at some length. 

"It is impossible in a discussion of so large a subject as diabetes to do more 
than present briefly a few points. The clinician, even of the most advanced 
modern type, who views the work that for the past ten years has been devoted 
to the intermediary metabolism of diabetes ought not to obtain the notion that 
this matter comprehends the substance of the disease entirely, and that upon the 
elucidation of the intermediary metabolism now under investigation depends our 
knowledge of the pathogenesis of the disease. Certainly, the laboratory investi- 
gator has no such conception. If up to the present the laboratory investigations 
have laid special stress upon the intermediary metabolism, it is because it is the 
most suitable phase for investigation. Nearly aU the studies deal with abnormali- 
ties in the catabolism of fat and sugar because these reactions lend themselves 
to investigation. But there is a broader view-point that every laboratory man 
must recognize, and which every clinician should understand, which may ex- 
plain many of the divergent features of diabetes. The up-building processes of 
the body can never be dissociated from the puUing-down processes. There is no 
such thing as a disturbance in the burning of sugar without an effect upon the 

^' Taylor, A. E., Tr. College Phys. Philadelphia, 1916, xxxviii, 254-255. 



GENERAL PLAN OF TREATMENT 129 

anabolism of sugar in the tissues, and likewise no disturbance in the burning of 
fat without similar influence in the building-up process of fat. Fat and sugar 
are vital in the building up of metabolism. We have every reason to believe that 
when the body cannot burn sugar and fat it cannot utilize sugar and fat in con- 
structive anabolism. Abnormalities in the utilization of sugar and fat in the 
building-up processes may be as important in the production of certain symptoms 
of diabetes deahng with resistance as are the abnormaUties in the catabolism. 

"I would, in the second place, draw attention to one point in connection with 
the current use of the Allen treatment, which is based upon a misconception. 
When the diabetic has been made sugar- and acid-free, how far shall he continue 
his dief ? Shall his increase of food be controlled by the urinary signs or shall he 
adopt other criteria? It has not been demonstrated that it is necessary to give 
the usually stated 40 calories per kilo. Investigations have recently shown that a 
man of 70 kilos may live sixty days upon a diet of coarse bread, potatoes, cheese, 
and eggs, containing about 2000 calories, without loss of weight. If such a man 
should happen to have diabetes and were subjected to the Allen treatment, it 
would be an absurdity to attempt to feed him back to 40 calories per kilo. The 
man dealing with a patient should bear in mind that what he needs to feed to 
is not the normally high maximum of calories but the low minimum standard of 
calories." 

As stated in the preliminary publications, in accordance with the 
principle underl3dng the entire treatment, the fact that a person is 
diabetic calls for restriction of his total diet, and, in proportion to the 
severity of the diabetes as indicated by the carbohydrate tolerance, 
the allowance of all three classes of foods should be diminished. With 
regard, to the necessary influence of such restriction upon body 
weight, it was advised that every patient, no matter how mild the 
diabetes, be kept a few pounds, preferably at least 10 or 15 pounds 
and in obesity more, below his usual former weight. In proportion 
as the diabetes is more severe, the weight as well as the diet should 
be kept lower. Overtaxing the anabolic side of metabolism by at- 
tempts to make patients carry too much weight will, in accord with 
Taylor's expression, bring a return of active diabetes manifested chiefly 
by excretion of products of deficient catabolism; while lightening the 
anabolic burden by reduction of body mass makes its benefit evident 
in an unproved catabolic function. 

There is a further interrelation between reduction of weight and 
diet. It is known from earlier metabolic studies that undernutrition 
reduces the food requirement not only absolutely but also relatively; 



130 CHAPTER n 

i.e., not only are there fewer kilograms of weight, but also fewer ca- 
lories are needed per kilogram. A recent illustration is afforded in the 
observation of Anderson and Lusk," that a dog after fasting 13 days 
showed a diminution of 20 per cent in weight and of 28 per cent in 
heat production. A special point in the study by Allen and DuBois 
lay in establishing the influence of this principle upon diabetic me- 
taboUsm. It was there shown that G. S. (patient No. 10 in the 
present series), starting with a basal metabolism 2 per cent above the 
average normal when severe diabetic symptoms were present, dropped 
to 21 per cent below normal on the eighth day of his fast. This 
calculation was based upon the DuBois height-weight formula; and 
as the weight was 31 per cent below normal, the reduction below 
tie original normal metabolism was far more than 21 per cent. The 
reverse change was demonstrated in W. G. (patient No. 8 in the 
present series). "Starting at 26 per cent below normal on January 
11, when glycosuria was absent, his metabolism rose, on increased 
diet and the return of active diabetes, to 20 per cent below normal on 
January 15 and to 11 per cent below normal on January 22." This 
patient was 42 per cent below his normal weight, so that the absolute 
reduction below his original normal energy exchange was far greater. 
These experiments carried out by DuBois estabHshed one essen- 
tial point in this theory of treatment; viz., that a relatively high me- 
tabolism accompanies active symptoms in the severely diabetic pa- 
tient, and that the fasting and low diet which control these symptoms 
enable him to descend to the low metabolic level proper to him as an 
emaciated human being, so that his maintenance requirement falls as 
low as that of any other equally emaciated individual. 

Lusk"* summarized the case studied by Geyelin and DuBois as 
f oUows : 

"When the patient was intensely diabetic, the number of calories produced 
per hour, as measured by the calorimeter, was 73.2. The weight of the patient 
was 56| kilograms. The heat production was normal for that weight. Later, 
through the starvation, the weight fell from S6J kilograms to 46 kilograms, and 
the man developed a high degree of tolerance for carbohydrate. The calories 

»' Anderson, R. J., and Lusk, G., J. Biol. Chem., 1917, xxxii, 421^45. 
'^Lusk, G., Tr. College Phys. Philadelphia, 1916, xxxviii, 244-248. 



GENERAL PLAN OF TREATMENT 131 

produced per hour fell from 76.4 to 43, or was 35 per cent under the normal for 
the lower body weight. Thus he requires only about 60 per cent of the food that 
he had required previously when he was heavier and diabetic." 

Patient No. 54 also was studied in the calorimeter by DuBois. The 
findings quoted in her case record show that the metabolism of this 
extremely emaciated woman was the lowest ever recorded, and 
"only 40 per cent of the original heat production was necessary for 
life." 

The nitrogen output of this patient was not correspondingly re- 
duced; and, though authors from Sivdn to Chittenden have demon- 
strated how low the protein metabolism of normal persons may be 
brought, it has been constantly borne in mind that protein is the 
most essential food and its reduction the most risky of all. It must 
be duly regtUated, not only because it is a food and a source of both 
sugar and acetone, but also because its specific dynamic action is 
greater than that of any other food in increasing metabolism. As the 
body weight is low, 1.5 gm. per kilogram have been arbitrarily chosen 
as a standard allowance of protein. Freedom from glycosuria is pos- 
sible on a higher protein ration with fat restriction than with 
unlimited fat. The new method therefore has the advantage over 
former ones in this respect, and is sufficiently elastic to allow such 
balance of the diet as may suit individual beliefs in favor of high or 
low protein. 

It is worth mentioning that the calorimetric results quoted have 
been obtained with ingestion of little or no carbohydrate. Persons 
acquainted with the literature need not be reminded that the in- 
crease of nitrogen excretion or of total metabolism on withdrawing 
carbohydrate or replacing it with fat applies only to high fat rations 
or to a certain standard of metabolism; for by lowering the level of 
nutrition it is always possible to reduce both total and protein metab- 
olism very low, even without carbohydrate. The slightly greater 
sparing power of carbohydrate is, however, one reason for retaining 
it in the diet, as noted below. 

Patients with the emaciation and minimal diet corresponding to the 
severest diabetes are necessarily far below normal in strength. The 
above mentioned investigation of Anderson and Lusk is of special 
importance with regard to the muscular activity of such patients. 



132 CHAPTER II 

These authors proved that when a dog was reduced in weight by 
fasting, there was a saving of energy when the animal ran in a tread- 
mill, because less energy was required to move the lighter body. But 
when the calculation was based upon the absolute work performed, 
the expenditure of energy was exactly the same before and after 
fasting; that is, the organism can economize in its basal metabolism, 
but the same absolute labor costs the same absolute energy, irre- 
spective of the state of nutrition. In diabetes, however, there are 
additional factors, namely the non-utilization of much of the energy 
contained in high diets, and the preternatural weakness and lassitude 
due to the resulting intoxication. Williams'^ has carried out a unique 
investigation by dynamometer tests of patients under treatment, 
demonstrating directly an increase of muscular strength when the diet 
is reduced so as to bring it within the metabolic capacity. 

The following are fair conclusions from the evidence at hand. Per- 
sons with mUd diabetes are as a rule easily enabled to maintain them- 
selves on mixed diets with moderate restrictions which reduce their 
weight but raise their efl&ciency and comfort practically to normal. 
Persons with moderate diabetes require more rigid restrictions, 
which bring them more or less below normal, but yet their diet is more 
agreeable and their comfort and usefulness maintained both higher 
and longer than on limitation of carbohydrate alone. Patients with 
severe diabetes necessarily face the hardest conditions. The investi- 
gations have shown the enormous load of useless and injurious metab- 
olism carried by such patients with their active symptoms, and the 
striking reduction of this burden under treatment which controls 
symptoms. The low metabolism and efficiency of inanition remain. 
There may be a tendency to calculate diets which appear absolutely 
low, but yet are luxus rations for this state and injure assimilation 
accordingly. The sympathy of the inexperienced onlooker is strangely 
greater for weakness and emaciation held in check by a tight rein on 
diet, than for the worse and rapidly progressive condition which, on 
overfeeding, appears as the simple consequence of the disease. It is 
possible for any case under unskillful restrictions, and for a few cases 
even under the most expert care, to end in actual death from starva- 

'8 Williams, J. R., Arch. Int. Med., 1917, xx, 399-408. 



GENEILA.L PLAN OF TREATMENT 133 

tion; but Joslin's and the present statistics agree in showing that this 
is not one-tenth as frequent as other causes of death, notably coma. 
Had circumstances permitted, the present series of cases might have 
afforded unusual material for a study of undernutrition, and might 
also have established the lower limits of a maintenance diet, which at 
present are unknown. It can only be said empirically that with re- 
markably few exceptions the curve of falling weight and the curve of 
rising assimilation meet at a level on which life can be maintained. 
The best experience seems to agree that, when such treatment is 
properly carried out, the unavoidable hunger and disabiHty are less 
distressing to all concerned than the troubles accompanying acidosis 
and complications under former methods. 

C. The Period of Observation and Instruction. 

Treatment can seldom be inaugurated or patients instructed as 
satisfactorily elsewhere as in a hospital with a well conducted metab- 
olism ward. This statement apphes not only to the critical cases, 
where the advantages are most evident, but even to the mildest ones. 

For the physician, a hospital offers the best facilities for the two 
prime essentials of treatment, accurate diet and laboratory control. 
He is also spared much unnecessary labor and inconvenience if the 
organization is right. 

For the patient, a hospital offers relief from work and worries, and 
both theoretical and practical education concerning diabetes. One 
test of treament is found in the fact that under proper conditions a 
patient is benefited by contact with other patients. Any fears con- 
cerning his own initiation are relieved on acquaintance with others 
who have gone through the same or more. He sees and hears the 
actual consequences of following or breaking diet, and his choice is 
generally for fidelity. He falls naturally, into the habits of his en- 
vironment, and learns so much from his neighbors and the general 
atmosphere of the place that instruction is made very easy. 

Much of the benefit of the early stage of treatment is often lost by 
undue brevity of the observation period. The extremely long hos- 
pital sojourn of most patients in the present series is accounted for 
partly by the severity of the cases, and partly by the requirements of 



134 CHAPTER II 

investigation. Few patients can remain in private institutions so 
long, but also comparatively few cases are so severe. It may seem 
that little is really being done after the first brief period of most active 
treatment, and that a longer stay imposes a cost in time and money 
which is unjustifiable, especially for poorer patients. It is unfortu- 
nate that poverty and necessity shorten the hospital period in- 
juriously in so many cases, and that public institutions are gener- 
ally so ill equipped to care properly for diabetics. Also much is ac- 
complished by the classes, clinics, and social service work conducted 
for diabetics by some of the best institutions and specialists. But, as 
a rule, the ideal hospital experience for a mildly diabetic patient can 
seldom be less than 2 weeks, and for severe cases the time may extend 
into months. 

For observation, this period is useful in order to determine the true 
food tolerance, so as to plan a diet which is neither too high, thus 
causing injury of assimilation and later relapse, nor too low, thus 
occasioning unnecessary privation and loss of weight. Laboratory 
tests, employed as described hereafter, are the chief means of judging 
progress. The patient should not be discharged until these tests give 
either normal results or adequate assurance of continued progress in 
the right direction. 

For instruction, this period is used to equip the patient with a 
sufiicient working knowledge of the care of his own case. Experience 
has shown that the simple essentials can readily be mastered by even 
the least educated persons, if they are willing and conscientious. 
Diets are readily calculated by the more intelligent patients, especially 
as the plan followed is so simple. Uneducated patients are sent out 
with fixed written menus, together with a list of absolute quantities 
of other foods which may be substituted for individual dishes on the 
standard menu. Before leaving, a patient generally spends most of 
his time for about a week in the diet kitchen, participating in 
the actual preparation of his own and others' diets. He is thus 
of some service, and at the same time acquires practice in cook- 
ing and calculation which guards against mistakes at home. . 
Men, women, and children alike are generally put through this prac- 
tical training; but when a relative, servant, or other individual will be 
largely concerned in the actual labor, this person is also given the 



GENERAL PLAN OF TREATMENT 135 

course of instruction. For testing the urine, the Benedict sugar 
method alone is sufficient, and can be learned by anybody. The 
tests, in severe cases or if the blood sugar is high, are best carried 
out upon the four separate urine specimens of each 24 hours, as done 
in the hospital. There is no harm in patients' learning as many lab- 
oratory reactions as they like, but the sugar test is really all they 
need to know, and they are more liable to become morbid over too 
many tests. Under proper conditions, only very rare patients are 
made nervous or hypochondriacal by performing their own sugar 
tests, so that these must be made for them by other persons. They 
must be equipped with definite knowledge of what to do if glycosuria 
appears. The best psychic state is generally assured when they 
know they are regularly and consistently sugar-free, and have confi- 
dence in their ability to control glycosuria if it appears. 

D. The Aeter-Care. 

The period of after-care properly extends over the remainder of the 
patient's life. For a considerable time at least, he should keep an 
accurate record of the facts pertaining to his case, most conveniently 
on a printed form supplied for the purpose. Such a record should 
include the naked weight, the exact diet, the urinary reactions, and 
the subjective health. No matter how thorough the instruction in 
hospital, questions and difficulties often arise, especially in the early 
period after returning home. The patient is encouraged to ask 
advice when needed, but particularly is ordered to report regularly at 
intervals ranging from one week in severe cases to several months in 
mild cases. Some reports may be made by letter, especially by pa- 
tients at a distance, but it is necessary for intelUgent supervision" 
that the patient present himself in person at definite times. Occa- 
sional emergencies also arise, and the patient should have some 
knowledge of how to meet them. For example, many may profit 
by the advice that in case of any infection, they should immediately 
omit fat from the diet. But such an emergency should be reported 
without delay to the physician in charge, in order that he may superin- 
tend any further measures necessary. 



136 CHAPTER II 

When a patient reports in person, his naked weight and a urine and 
a blood sample are taken. The accuracy of his record is thus checked. 
If the blood sugar is normal, and the nitroprusside test is negative in 
urine (Rothera) and in blood plasma (Wishart), practically nothing 
else is needed. If all is not so favorable, such other analyses are 
performed as may be necessary to show whether there is danger or 
what is the direction of progress. 

These occasional tests are the guide for such adjustments of diet 
as may be necessary from time to time. The severely diabetic 
patient requires rather close supervision for checking wrong tenden- 
cies in their incipiency and for the best results in general. The en- 
couragement and moral support gained in personal contact are fur- 
thermore specially important in the severe cases, though a high pro- 
portion of milder cases without it will sooner or later go wrong. A 
case lost from sight is generally a failure. Milder diabetes should not 
involve invalidism or irksome dependence; but these persons, even 
while leading comfortable and useful lives, should keep in touch with 
their medical adviser, for experienced oversight of their condition and 
diet and for information concerning advances in treatment. 



V. Ideals of Diet and Laboratory Control. 

In the earliest preliminary outlines of this treatment, the plan was 
defined as an attempt to spare a weakened function by rest, and to 
this end it was proposed to make and keep every patient free from 
glycosuria and from obvious acidosis. This initial step appeared as a 
sufi&ciently radical, even hazardous, departure from the former man- 
agement of severe cases; and it was hoped that there might be more or 
less improvement in such assimilative function as remained to these 
patients, corresponding to the gain in tolerance known to occur when 
the symptoms of milder diabetes were cleared up under the old treat- 
ment. The reality of such improvement in many of the most intense 
cases in their earlier stages is now a familiar fact, and is discussed in 
Chapter VII. Even in the first patient, however, the inability to 
gain in assimilation to any important degree was manifest, and other 
cases quickly confirmed the fact that prolonged severe diabetes was 
characterized under this plan by permanently low food tolerance, 
and that downward progress was merely delayed and not prevented. 
The obvious path for investigation was to determine whether the 
degree of functional rest represented by the crude tests originally se- 
lected is adequate for such extremely severe cases of diabetes as 
were intentionally selected for trial of the treatment; and this also 
would have answered the question whether or to what extent there 
is a genuinely spontaneous downward progress in diabetes of any 
type. At this earliest period, the question was discussed with 
Joslin whether it might not logically be required to abolish hypergly- 
cemia rather than merely glycosuria, and whether it is possible to 
bring the blood sugar to normal in the severest cases. Under the con- 
ception of diabetes as a weakness of the total metabolism, it would 
have been necessary to carry out simultaneous studies of the carbo- 
hydrate, protein, and fat functions; to determine whether overstrain 
of any side of metabolism was present; whether such overstrain was 
demonstrably injurious; and whether the overstrain and injury could 
be obviated. Such' studies upon a few cases would have given an 

137 



138 CHAPTER n 

early answer to the essential question. In the first patients, it was 
not possible to perform even blood sugar analyses. With the expan- 
sion of laboratory facilities, the therapeutic problem became replaced 
by others; and in consequence, treatment was applied to a long 
series of patients over a long period of time with no advance over the 
original crude criteria. That is, negative sugar and ferric chloride 
reactions in the urine were maintained if possible, as originally rec- 
ommended; but hyperglycemia, ketonemia, and the excretion of sev- 
eral grams of acetone bodies with increased urinary ammonia daily, 
as shown in the records, were allowed to continue without investiga- 
tion of their possible consequences or the development of any further 
means to combat them. 

This poKcy has been followed by disastrous results, both in the 
present series, and in the experience of others with the same method. 
Meanwhile, experiments upon partially depancreatized dogs have 
shown similar conditions. After suitable operation, a dog on a given 
diet may be free from glycosuria and yet have hyperglycemia. One 
of two things happens. Either the hyperglycemia passes off and the 
animal lives indefinitely, or hyperglycemia persists, with or without 
ketonuria, and the progressive decline duplicates that of corresponding 
human diabetics. This outcome in animals which are demonstrably 
free from spontaneous downward tendency furnishes decisive proof 
that this degree of functional overstrain may of itself produce this 
result. 

This fact does not conflict with the observation of Mosenthal, 
Clausen, and Hiller^" concerning the stubbornness of the tendency to- 
hyperglycemia in severe diabetes. For practical reasons, it may some- 
times be necessary to allow patients to go along with this level of 
blood sugar which assists their defective power of combustion, appar- 
ently by mass action. It is surprising how well many patients can. 
do under such conditions, and for how long a time. But the down- 
ward progress which ultimately follows this overstrain cannot prop- 
erly be called spontaneous. Also, the greater the genuine severity 
of the case, the more quickly and obviously does this continuous, 
hyperglycemia bring disaster. It is belifeved that the utmost effort 

^0 Mosenthal, H. O., Clausen, S. W., and Hiller, A., Arch. Int. Med., 1918, 
xxi. 93-108. 



GENERAL PLAN OF TREATMENT 139 

should be made to maintain normal blood sugar at any stage; but 
above all, proper treatment demands that a case be so managed from 
the earliest diagnosis that the tendency to hyperglycemia shall be 
prevented or delayed as long as possible. 

The conditions described above do not apply to dogs with pancre- 
atic atrophy or to occasional human patients with organic disease 
obviously progressive in character and causing decline irrespective of 
diet. Time has not yet permitted answering the other half of the 
question; viz., whether the great mass of typical diabetic patients are 
ultimately subject to downward progress even when all functional 
overstrain is relieved as far as ascertainable. 

As shown in Chapter VII, results have been decidedly best when 
early cases of diabetes have been so treated as to keep them normal 
to all the chemical tests used. In resuming the therapeutic prob- 
lem recently, difficulty was anticipated in a large proportion of more 
advanced cases, because the hyperglycemia is often very refractory 
to fasting. It has proved possible, however, to achieve a normal 
blood sugar in almost all cases on a plan prompted by the following 
reasoning. 

Reduction of body mass has been a regular means of improving 
assimilation. But if it were desired only to relieve of his obesity 
one of the fat patients in the series, the best method would be neither 
plain fasting nor a haphazard mixed diet. The rational diet for 
obesity is one containing protein to protect body nitrogen and bulky 
vegetables to fill the stomach, while low in calories so as to compel com- 
bustion of body fat. An obese person can endure such a treatment, 
when on plain fasting he might become dangerously weakened before 
his weight was sufficiently reduced. The same considerations apply 
with greater force to weakened diabetics. By subjecting these 
emaciated patients to an obesity cure, their weight has been reduced 
sufficiently to conquer their hyperglycemia. This means, in practical 
application, that after the initial fast and carbohydrate test, if the 
blood sugar is still high, the patient receives a diet in which the only 
real food is protein, generally about 1 gm. per kilogram of body 
weight. Body nitrogen is spared and strength maintained better 
than on plain fasting, and the program is continued until the blood 
sugar falls to 0.1 per cent. The specimen laboratory chart facing 



140 CHAPTER n 

page ISO illustrates such a treatment, through the periods of the 
initial fast, the carbohydrate test, then the protein diet till the blood 
findings are normal, and fina,lly the mixed maintenance diet. Rare 
cases are so severe that both hyperglycemia and ketonuria persist 
for weeks on this exclusive protein diet. Here it has been necessary to 
keep the patient for a week or two on a diet with negligible food values, 
viz. soup, bran, agar jelly, and thrice cooked vegetables, in order to 
obtain normal blood sugar, which may then contmue on the above 
protein diet. Protein is increased if possible to 1.5 gm. per kilogram 
of weight. The first food added to it is carbohydrate, and a patient, 
according to severity, is required to assimilate 5 to 20 gm. without 
hyperglycemia, and thus to be free from any trace of ketonuria, be- 
fore proceeding to the gradual addition of fat. The limit of fat and 
calories in the maintenance diet is governed by laboratory tests. 
The importance and interpretation of these tests change in the later 
observation period from what they were at the inception of treat- 
ment, and a few remarks may be devoted to the three phases of 
metabolism involved. 

Protein. — No direct tests of protein metabolism are required in the 
late observation period. Most important would be total nitrogen 
analyses in any case of doubt concerning the nitrogen balance, but 
on the protein allowance recommended the patient ordinarily comes 
into nitrogen equilibrium with simple clinical observation. Am- 
monia is always normal if acidosis is controlled as described. Un- 
published analyses in this laboratory have shown that in the most 
intense active diabetes there is increase of amino-acids both in the 
urine, as reported in the literature, and in the blood; but this, like the 
exaggerated nitrogen catabolism, is regularly absent under the 
routine treatment. Sufficient warning of an overtaxed protein me- 
tabolism is afforded by hyperglycemia or ketonuria. 

Carbohydrate.— With. Benedict's method,*^ it is now as easy to de- 
termine the sugar in blood as formerly the sugar in urine, and really 
simpler and more satisfactory to make the analysis than to send the 
blood to a laboratory. One hindrance to its use by practitioners has 

" Lewis, R. C, and Benedict, S. R., /. Biol. Chem., 1915, xx, 61-72. Benedict, 
S. R., ibid., 1918, xxxiv, 203-207. Bock, J. C, and Benedict, S. R., ibid., 1918, 
XXXV, 227-230. 



GENERAL PLAN OF TREATMENT 141 

been the cost of a colorimeter, which has been met by the introduction 
of the Bock and Benedict^' instrument. Epstein' s*^ modification of 
the Benedict method, though not quite so accurate, is the sim- 
plest and cheapest of all and requires only a few drops of blood, ob- 
tainable from the ear or finger. A large number of physicians whose 
tests must be made in their own offices and who would never under- 
take a more elaborate method, will undoubtedly make use of this 
device, and will have no excuse for being without blood sugar analyses. 
Knowledge spreads rapidly among diabetic patients, and instead of 
objecting to the drawing of blood many of them doubtless will soon 
be demanding it. 

If the blood sugar is kept normal, urine tests are almost superfluous. 
The patient has the agreeable knowledge that glycosuria is always 
absent, and his tests merely guard against errors in diet or any un- 
foreseen change. The blood sugar is one of the most delicate indi- 
cators not only of the carbohydrate but of the total metabolism. 
Even though glycosuria be absent, a dangerous lack of control of the 
diabetes is indicated in those instances where the blood sugar actu- 
ally rises after one or several days of fasting. It is sometimes but not 
necessarily associated with a correspondingly unfavorable change in 
the acidosis. The h3^erglycemia after carbohydrate ingestion rises 
and falls relatively quickly. There is a more gradual rise and fall 
after protein. The absence of hyperglycemia after feeding pure fat, 
and the slowness of the rise of blood sugar on adding fat to a diet, 
are in accord with the accepted belief that fat is not converted directly 
into sugar; but the h3^erglycemia is particulatly lasting and stubborn. 
The limit of fat in a maintenance diet is reached when hj^erglycemia 
results from its further addition to the ration of protein and carbo- 
hydrate which has been fixed as necessary. The ideal is that the 
blood sugar shall not be above 0.1 per cent fasting or above 0.15 per 
cent during digestion.^ 

*^ Epstein, A. A., /. Am. Med. Assn., 1914, Ixiii, 1667-1668. Instrament with 
instructions obtainable from Ernst Leitz, 30 East 18 Street, New York City. 

■*'As this monograph goes to press, the first of a sferies of papers from the 
laboratory of S. R. Benedict, who has already contributed so preeminently in the 
field, are appearing in The Journal of Biological Chemistry, 1918, xxxiv, 195-262. 
The application of a newly perfected method, which determines quantitatively 



142 CHAPTER n 

Fat. — The two direct evidences of disordered fat metabolism are 
acidosis and lipemia, which will be considered separately. 

Acidosis. — Quantitative tests are necessary precautions when 
acidosis exists; but as far as now known, there is no danger from 
diabetic acidosis if the nitroprusside test is negative in both urine 
and blood plasma." It has proved possible to keep the reaction con- 
sistently negative in some of the severest cases of diabetes. A ques- 
tion is possible whether strictness to this degree is necessary: whether 

the sugar even in normal urine, gives promise of results of the highest importance 
in the study of sugar tolerance and carbohydrate metabolism. The prediction 
may be ventured that such a refined method will reveal a pathological excretion 
of urinary sugar by diabetics with the familiar marked hyperglycemia. In- 
vestigation will have to show whether the urine becomes normal for sugar when 
the above requirements of normal blood sugar are fulfilled. It is to be empha- 
sized that the essential progress and improvement of clinical results must lie in 
this direction of finer methods, earlier diagnosis, and stricter control of incipient 
abnormalities. Only by such means can the principle of treatment by sparing 
a weakened function be carried out successfully. 

** Legal (Z. and. Chem., 1883, xxii, 464) first observed that the nitroprusside 
reaction (originated by Weyl as a creatinine test) might serve as a test for acetone 
and acetoacetic acid. V. Arnold {Centr. inn. Med., 1900, xxi, 417), by fine 
quahtative tests showed that acetone is excreted only in the severest grades of 
acidosis, while the substance present in ordinary so called acetonuria is aceto- 
acetic acid. Embden and Schliep {Centr. ges. Physiol, u. Path. Stqffwecks., 
1907, ii, 289) found quantitatively no preformed acetone in the fresh urine in 
some cases of ketonuria, and in other cases it ranged about 1/10 to 1/4 of the total 
acetone bodies. Folin and Denis (/. Biol. Chem., 1914, xviii, 267) stated that 
"acetone urines contain from two or three to nine or ten times as much aceto- 
acetic acid as acetone." Rothera (/. Physiol., 1908, xxxvii, 491) regarded his 
improvement of the nitroprusside test as a test for acetone; but W. H. Hurtley 
{Lancet, 1913 (1), 1160) proved that with pure materials the Rothera reaction is 
sensitive to acetoacetic acid in 1 to 400,000 dilution, but to acetone only in 1 to 
20,000 solution. Kennaway {Guy's Hasp. Rep., 1913, Ixvii, 161) confirmed the 
fact that the Rothera test is essentially an acetoacetic test which is at least 25 
times as deUcate as the Gerhardt ferric chloride reaction; and he suggested that 
the greater opportunity and ease of diffusion through the lungs as compared 
with the kidneys is the reason why most of the preformed acetone leaves the 
body through the former. There is no simple qualitative test for /3-oxybutyric 
acid. To some extent the intensity of the acetoacetic reactions serves as a rough 
index of the quantity of both acids present, but there are wide departures from 
this rule in both directions. 



GENERAL PLAN OF TREATMENT 143 

normal persons with identical nutrition would not show slight keto- 
nuria, and whether it may not be harmless. There is an opposite 
speculation whether a diet or metabolic state productive of keto- 
nuria is not more or less harmful even to normal persons, and whether 
a diabetic may not be more susceptible to injury. The presence of 
|3-oxybutyric acid out of proportion to the small acetone-acetoacetic 
"fraction seems to characterize some of the long standing severe cases. 
Any considerable ketonuria in severe cases is associated sooner or later 
-with hyperglycemia. When the blood sugar is low, faint nitroprusside 
reactions have been allowed to exist in some patients, without empiric 
evidence of harm. While ketonuria is most closely associated with the 
fat ration, it can result directly or indirectly from unwise addition of 
•any kind of food to the diet. When acidosis in the strictest clinical 
•definition is kept absent as described, the plasma bicarbonate is regu- 
larly high, generally above rather than below 65 per cent. 

Lipemia. — ^The investigation of this subject is apparently of rapidly 
;growing importance. It has long been known that some cases of dia- 
betes are characterized by lipemia far in excess of anything found in 
any other condition. Some of the facts recently established^ are 
that the blood fat may be several times the normal without notice- 
able turbidity; that the lipoid relations, especially the high cholesterol, 
-are in contrast to normal alimentary Hpemia; that in severe diabetes 
the hyperlipemia is apparently as constant and characteristic as the 
Tiyperglycemia, and that it is largely associated with the fat intake 
and with other active diabetic sjonptoms. At present, the findings 
•seem to support the conception of diabetes as a disorder of the 
total metabolism, and to furnish further evidence against the mis- 
leading practice of labelling phloridzin, adrenalin, or other forms of 
-sugar excretion as "diabetes." The question immediately arises 
whether excess of fat in the blood is not as truly indicative of over- 
^strain and injury as excess of sugar. It is also essential to know 
whether the rigid program above outUned brings the lipoids as well as 
other blood constituents to normal. The work of Gray^^ shows actu- 
.ally low levels of blood fat in some severe cases under strict treat- 
ment. Many analyses are also under way in this hospital. It is 

"Allen, Am. J. Med. Sc, 1917, cb'ii, 313-371. Gray, Boston Med. and Surg. 
J., 1918, clxxviii (references to Bloor and Joslin). 



144 CHAPTER II 

not yet certain whether fat determinations are necessary for guid- 
ing treatment at this stage. The blood sugar and nitroprusside tests 
may perhaps suffice. 

It should be emphasized that comparison and clinical judgment are 
necessary in interpreting the significance of all laboratory tests. It is 
wholly erroneous to consider that hyperglycemia, ketonuria, or any 
other laboratory finding is in itself proof of a breaking strain upon 
metabolism, or that absence of such indications gives assurance that 
all is well. As in dogs, so in patients, hyperglycemia may gradually 
subside on right diet or may gradually develop on wrong diet. The 
same is true of ketonuria, and doubtless also of lipemia. Some pa- 
tients in this series have been discharged with marked hyperglycemia 
and ferric chloride reactions present. These persisted for months, 
but yet the policy was safe, because it was recognized clinically that 
the cases were essentially mild diabetes, and that these symptoms 
would gradually clear up, without requiring that an elderly or weak 
person be subjected to more serious privations. Such liberties with 
a severe case, even though tlie remaining symptoms be slight, are 
risky; and they are disastrous with any case unless the diet is within 
the actual tolerance. It is highly important not to treat an incipient 
case of potentially great severity as if it were a genuinely mild case. 
Also, in some severe cases in this series, the blood sugar was sometimes 
brought to normal by withdrawal of carbohydrate, with a diet too 
high in fat and calories. More or less ketonuria was present, and 
doubtless the blood fat was high. Notwithstanding absence of hyper- 
glycemia for weeks or months on carbohydrate-poor diet, such a case 
can be expected to go steadily downhill. The character of the case, 
comparisons of different tests, and the direction of progress are there- 
fore important guides in treatment and prognosis. Too much em- 
phasis upon any single test may be as misleading as the lack of tests; 
and though laboratory work should never be slighted, the experienced 
man with very simple means will administer far better and safer 
treatment than the tyro with a great laboratory at his disposal. 
The ideal treatment therefore begins with rather extensive laboratory 
study, but in the end comes down to a very few simple tests. 

While discussing ideals, the fact should be plainly faced that the 
program above suggested is for very severe cases an excessively rig- 



GENERAL PLAN OF TREATMENT 145 

orous one. The patients of this extreme type are weakened by it; 
sometimes they must be temporarily kept in bed; and their physical 
and psychic depression becomes greatest at about the time the blood 
sugar becomes normal. No disaster has occurred under the method, 
and none of these patients has refused it. Strength returns when a 
maintenance diet is resimied; sometimes it seems as great as before, 
but more often the fall in both flesh and strength is noticeable. In 
view of the questionable prognosis in such extreme cases at best, 
the conservative physician will ask himself whether it is advisable to 
impose such privation, especially as inanition and the dangers of 
chance infections are obviously brought closer. In a few cases, mod- 
erate hyperglycemia and shght nitroprusside reactions without other 
symptoms have been permitted in the interests of strength and 
efficiency. Similar ideals have suggested themselves to a number of 
the best workers in this subject, on account of their similar mishaps 
with the less careful methods. As far as known, however, both the 
plan and execution of the above program are new. It has been appHed 
because the patients wished to live, and because it was certain that 
they would die soon unless saved by radical measures. Their sub- 
jective comfort after the rigid treatment has been about the same as 
before. The downward progress formerly evident has in every in- 
stance been either arrested or delayed — the few months of experience 
do not permit answering which. It is not certain whether such a 
method is to be generally recommended in practice, and in any event 
there is no desire to urge it upon either physicians or patients. It is 
fairly certain that the rigid plan will prolong life and also maintain 
a fixed level of nutrition, if not indefinitely, at least considerably 
longer than laxer methods. If hyperglycemia, ketonuria, and other 
symptoms are allowed to persist, a definitely gloomy prognosis must 
be accepted, and the choice is essentially either death in coma or pro- 
gressively more severe undernutrition, which becomes more extreme 
than required under the rigid plan and increases to death in starva- 
tion. The above quaUfications apply, however, only to these cachetic 
patients with excessively severe diabetes. The greatest importance 
of the plan lies in its application to earlier cases, and for these it is 
strongly and unreservedly recommended. In the early stage it is 
shorter and easier to carry out, involves no extreme privation or 



146 CHAPTER II 

physical deterioration, and fulfills the purpose of relieving metabolic 
strain as far as present analytic methods can determine. It has 
thus far demonstrably prevented downward progress in several cases 
of the type which ordinarily progress downward, and it offers at least 
a chance of continued subjective health, whereas looser methods prom^ 
ise nothing but death. 

When the blood sugar is normal, glycosuria from trivial carbohy- 
drate ingestion does not occur. Accurate reckoning of the diet is 
just as essential; but yet if glycosuria results from slight fluctua- 
tions in the carbohydrate content of vegetables, or from adding a few 
hundred grams of thrice cooked vegetables, the patient is certainly 
too close to the verge of his tolerance and trouble will follow unless 
the condition is improved. There are the following reasons for giv- 
ing carbohydrate as prominent a place in the diet as feasible. First, 
it gives the quickest and most harmless danger signal. Second, at 
least a small quantity is necessary to fulfill the ideal of freedom from 
ketonuria. Third, it spares protein more effectively than fat, and 
incidentally spares the total metabolism somewhat; and as shown by 
Zeller,*^ if the carbohydrate of the ration is equivalent to one-tenth 
of the fat calories, the sparing is as effective as though all the fat were 
replaced by carbohydrate. Fourth, by permitting a supply of fresh 
green vegetables, it makes a diet more agreeable and satisf3dng than a 
higher carbohydrate-free ration. Fifth, on general principles and for 
reasons partly unknown, a mixed diet is the only natural diet, and 
no diabetic will ever live long on any other. Caution is needed 
against the mistake conamitted by some, in giving so much carbo- 
hydrate that a living ration of protein and fat is made impossible. 
But as stated, the rule in this hospital recently has been to reduce 
the total diet sufficiently to enable any patient to assimilate at least 
5 gm. of carbohydrate, and correspondingly more in the less extreme 
cases. 

Various methods of treatment have been tried in the present 
series. At one extreme there has been reversion to the old practice 
of carbohydrate-poor diets of 40 calories per kilogram or more. 
At the other extreme are a few cases treated according to the rigid 

^"ZeUer, H., Arch. Physiol., 1914, 213-236. 



GENERAL PLAN OF TREATMENT 147 

program last outlined. The results shown are therefore not those of 
any one method. The results of different methods should be compared 
and the choice of treatment governed accordingly. The experience 
is believed to support the original principle that treatment should 
aim to spare a weakened total metabolism, and that in proportion as 
carbohydrate must be restricted, the total diet should also be kept 
low. 



VI. Practical Management of Diets. 
A. Organization. 

Many physicians and hospitals have found it possible to conduct 
diabetic treatment more or less successfully under adverse conditions. 
Foods may by special arrangements be served from the general kit- 
chen if necessary. Though some patients in the present series, es- 
pecially in observations requiring accuracy, have been isolated in 
individual rooms, others have been in open wards with patients suf- 
fering from other diseases. Their own fidelity, and the knowledge 
that glycosuria and fasting would follow an indiscretion, have main- 
tained a high general average of good conduct. 

The ideal arrangement, and the one which is being rapidly adopted 
by the best hospitals, is to organize a special diabetic or metabolic 
ward, with a separate diet kitchen in as convenient proximity to it 
as possible. The kitchen organization here, and the cooperation of 
Miss Emmeline Cleeland, the diet nurse, have contributed much to 
the success of the work. 

The head of the kitchen may be either a specially quahfied nurse 
or a trained dietetian who is not a nurse. Her time is best left 
free for duties of supervision. The physician has merely to order a 
diet in terms of protein, carbohydrate, and calories. The nurse then 
translates these figures into the actual foodstuffs, superintends the 
cooking, and is responsible for the accurate recording of everything 
pertaining to the diet. She maintains a sympathetic acquaintance 
with all patients, takes care that the selection and preparation of food 
suits their tastes as well as possible, and by smoothing small diffi- 
culties contributes greatly to lighten the lot of the patient and the 
labor of the physician. Under some circumstances it may be con- 
venient for one nurse to have charge of both the kitchen and the 
ward, and to supervise also the qualitative testing and recording of 
the urine. 

The assistant diet nurses vary in number with the number of 
patients and the degree of detail required. Labor is saved at the 

148 



GENERAL PLAN OF TREATMENT 149 

expense of some slight inaccuracy by weighing certain foods after 
cooking, by estimating certain other foods, etc. Servants at lower 
wages can save both the nurses' time and some of the more dis- 
agreeable features of the work. In this hospital every kind of food 
has been weighed accurately raw, and cooked separately for each 
patient. With this arrangement, one assistant nurse for about eight 
patients has been needed. If the service is rotating, an assistant 
nurse should if possible spend at least three months in the kitchen con- 
tinuously; otherwise both time and accuracy are sacrificed in teaching 
new nurses. At the end of the three months she should be familiar 
not only with the cooking but also with the duties of the head nurse. 

B. Equipment. 

The equipment is mostly that of an ordinary kitchen. A few 
special articles have been found useful, as follows: 

Diet scales. — An accurate spring balance has been used for weighing 
the individual food portions. In construction it is similar to the or- 
dinary letter scales. This model is manufactured* by Chatillon and 
Company, 85 Cliff Street, New York. The price, formerly $5.00, is 
now $7.50. Each patient buys such a balance preparatory to return- 
ing home. The dial is movable, so that it can be set at zero after 
the dish for receiving food is placed on the weighing stage. The 
weight of the food can then be read directly in grams. The quickness 
and convenience of such an instrument is important for prolonged 
fidelity in weighing food, for few patients will trouble themselves 
through months and years with the tediousness of ordinary scales 
and weights. 

Steamer. — A well known form of steam cooker has been used for 
cookirig vegetables without loss of carbohydrate. The reservoir at 
the bottom contains water; the compartments above hold the vege- 
tables. As the steamer is constructed on the unit system, few or 
many of the compartments may be used at any time as needed. By 
this means a number of different vegetables can be steamed simul- 
taneously, and the more easily cooked ones can be removed before 
the others. 

Slide Rule. — Nurses who are to calculate many diets can save time 



150 CHAPTER n 

and trouble in multiplication by learning to use a simple slide rule. 
A convenient one is the "Merchant's," obtainable from the Keuffel 
and Esser Company, 127 Fulton Street, New York City. 

Adding Machine. — ^Additions have been performed with the Golden 
Gem Adding Machine, manufactured by the Automatic Adding 
Machine Company, 148 Duane Street, New York City. A small and 
inexpensive instrument of this sort aids not only in time-saving but 
also in accuracy. 

Records. — ^A twofold record of diets has been kept. A more de- 
tailed separate diet chart shows each individual food item for each 
meal, together with the totals, as illustrated in the specimen diets 
hereafter. A statement of the totals for the day is also entered in 
the laboratory chart, in order that the relation between diet and 
laboratory findings may be evident at a glance. 

One general form of laboratory chart has been used since the early 
organization of the work, with slight modifications as needed from 
time to time (Table III). It measures 30 by 90 cm., and folds so as 
to conform to the clinical charts. In the table two figures are given 
for carbohydrate, protein, and fat for each day. The upper figure (in 
bold face type) denotes calories, the lower figure (in ordinary type) 
grams. For convenience in entering on the chart, the two figures 
are written in the form of a fraction; the figure above the line 
(calories) is written in red ink, that below the line (grams) is 
written in black ink. Formerly there was a column for alcohol, 
but this has been dropped, and if alcohol is given on any rare occasion, 
it is written into the total calory column. There also was formerly a 
column for sodium bicarbonate, but as this is so seldom used, the 
column has been discontinued and any occasional doses of alkali en- 
tered in the "Remarks" colimin. Among foods, three colimms are 
found under "Bacon," the abbreviations indicating the three forms 
in which it is served; first whole bacon; second crisp bacon, fried so 
as to reduce the fat content as low as possible; third the clear bacon 
fat, practically free from protein. These three forms serve different 
purposes, and yet the advantage of the bacon flavor is retained. The 
two columns under vegetables show the total weight respectively of 
carbohydrate-containing or thrice cooked kinds. The various "Re- 
marks" columns give room for additional analyses or special notes, 
explanations, time of day, etc. 



GENERAL PLAN OF TREATMENT 151 

C. Notes on Special Features of the Maintenance Diet. 

1. Fast-Days. — Occasional single days of fasting or greatly reduced 
diet have been prescribed in the after-treatment of all cases. They 
are taken at regular fixed periods, the length of the interval and the 
rigor of the program being proportioned to the severity of the diabetes. 
In the typical severe cases, a fast-day is taken once each week, the 
patients generally choosing Sunday for the purpose. In even the 
mildest cases, such a day is ordered at least once a month, more 
commonly once every 2 weeks. Individuals react differently. Some 
go about their usual affairs; others are comfortable in bed; others 
become weak and depressed. When discomfort persists even after 
habituation, and in any mild case when desirable, the ordeal is miti- 
gated if possible. The addition of a few hundred grams of thrice 
cooked vegetables to the bran, soup, and coffee of an ordinary fast- 
day may give relief. Especially in milder cases, vegetable days are 
useful; not the old fashioned kind with fat and other additions, but 
only vegetables containing such carbohydrate as will not raise the 
blood sugar above 0.15 per cent and will leave it not above 0.1 per 
cent on the following morning. Protein and other foods necessarily 
diminish the benefit of a fast-day in proportion as they are allowed. 
Von Noorden's designation of fast-days as "metabolic Sundays" is 
suggestive. There is no evidence whether the same number of calories 
weekly will be borne any differently if distributed over 7 or 6 days. 
But as the body in other respects seems to function more efficiently 
by working 6 days and resting 1, it is possible that a similar prin- 
ciple may apply to metabolism; also, the patient may perhaps feel 
and work better if he takes the larger ration on 6 days and relaxes 
as completely as necessary on the 7th. The occasional relief from the 
metabolic burden may also be beneficial in even the mildest cases, in 
guarding against downward progress and in atoning for any chance 
indiscretions. Such days of special restriction are also a strong re- 
minder of the existence of diabetes and the need of continuous precau- 
tion, so that they aid instead of hindering discipline. Regular fast- 
days are intended for prevention of symptoms. When fasting is 
compelled by the actual occurrence of glycosuria or hyperglycemia, 
the diet is wrong and must be changed. , 



152 CHAPTER n 

2. Water. — There is no objection to mineral waters, but they are 
without special virtues and are unnecessary when good plain drink- 
ing water is available. Mineral springs and resorts should be rated 
solely according to the efficiency of their dietetic treatment, and in as 
far as curative influence is attributed to the water they constitute an 
unfavorable environment. 

3. Alcoholic Beverages. — As stated, all alcohol habits are best dis- 
couraged, and as the calories of alcohol must strictly be counted in a 
limited diet, the patient will generally prefer more wholesome food. 
Light wines, as low as possible in both carbohydrate and calories, are 
probably best for those with whom alcoholic beverages are a habit 
too firmly fixed to be broken. 

4. Coffee or Tea.— The use of weak tea or coffee, or Kaffee Hag, not 
more than three cups daily, has already been mentioned as permis- 
sible with fasting or any diet, except that a coffee habit has not been 
cultivated in persons not addicted to it. Joslin often substitutes a 
drink made of cocoa hulls. 

5. Milk. — Sugar-free milk of satisfactory taste is prepared by 
D. Whiting and Sons, 570 Rutherford Avenue, Boston, Mass., and its 
keeping qualities are such that it can be shipped long distances. 
Little use has been made either of it or of home-made preparations of 
casein and washed cream (i.e. cream mixed with large volumes of 
water to remove lactose, and skimmed off after rising or centrifuga- 
tion). Milk is important for children, but it is considered the best 
policy to regulate their total diet so as to create sufficient carbohy- 
drate tolerance to enable them to take natural milk. Sugar-free 
milk would thus be needed only temporarily, or as part of the diet of 
diabetic infants. 

6. Soup. — Thin soup made from bones or stock contains very little 
nutrition, but its warmth and flavor are highly gratifying, and it also 
supplies salts, and aids in serving bran biscuits, thrice cooked vege- 
tables, and other articles having httle taste. It has been allowed in 
quantities of 300 to 600 cc. daily, during fasting, carbohydrate tests, 
and all other diets. Sometimes beef tea, made from beef extract, 
has been used as a means of avoiding even the small quantities of 
protein of ordinary soup. 



GENERAL PLAN OF TEEATAIENT 153 

7 . Salt. — Probably because of the rather monotonous and unsatis- 
ifying diet,' patients with severe diabetes often crave surprising quan- 
tities of salt. Many of them develop edema on unrestricted salt 
intake. The susceptibility of individuals differs. Though no real 
harm has been seen from the edema, salt-free diet has sometimes 
temporarily been necessary to remove it, and for all severe cases 
sodium chloride is given in a weighed daily allowance like other 
items in the diet. The limit has commonly been 5 gm. daily; some- 
times only 3 gm., occasionally as much as 8 gm. Numerous glass 
tubes containing such weighed quantities of salt are kept on hand 
in the diet kitchen. The nurse uses a part of the day's allowance for 
seasoning, and the rest is placed in a small salt shaker on the pa- 
tient's tray, to be used at his discretion with one day's meals. The 
craving is generally not noticed when limitation of the supply pre- 
vents forming the abnormal habit. 

8. Meats. — Meats are included in the diet according to their food 
value and the tastes and digestion of the patient. Eggs and vegetable 
proteins are available on the same basis. No indications of specific 
differences between proteins and no advantages in vegetarianism have 
been observed. For a low protein vegetarian diet, it would be neces- 
sary to use care in selecting the kinds of protein, to assure an adequate 
supply of all indispensable amino-acids. 

P. Fats. — These are chosen on a similar basis of suitability; There 
is no need to pay attention to the content of higher or lower fatty 
acids from the standpoint of ketonuria. If anything, butter is pref- 
erable to olive oil. 

10. Raw and Steamed Vegetables. — Since carbohydrate is desirable 
in the diet, it is obviously preferable to use vegetables without ex- 
traction when possible. Even ordinary boihng is a partial extraction. 
Therefore, for accurately retaining the food value, vegetables have 
been served either raw or steamed in the steamer above described. 
Additional mention may be made of canned vegetables, which are 
used either in this way or after thrice cooking if necessary. Canned 
or dried vegetables are important aids to the winter diet. 
Patients sometimes prepare their own supply in summer. The ad- 
vantage of giving carbohydrate in the pleasant, varied, bulky, and 
satisfying form of vegetables, rather than in smaller quantities of 



154 CHAPTER II 

bread or cereals, is obvious. With green vegetables, eggs, butter, 
etc., there should be no fear of a lack of vitamines or other accessory 
substances in the diabetic diet. 

11. Thrice Cooked Vegetables. — ^Whatever time a vegetable requires 
to cook is divided into three approximately equal periods, and the 
boiling water changed so as to make three extractions of carbohy- 
drate. Each patient's portion is made ready for cooking as usual, 
weighed raw, and tied loosely in a single layer of cheese-cloth, and 
the portions for different patients thus boiled together in one large 
pot. The thrice cooked vegetables have been used to contribute 
bulk with negligible food value. They are so important for this 
purpose that the treatment would in some cases be almost impossible 
without them, and they -add much comfort in other cases not quite 
so severe. The different kinds of vegetables vary in the degree to 
which they retain their flavor, but most are palatable and some are 
practically as appetizing as with ordinary cooking. 

Their empirical use without analyses has entailed some uncertainty 
and inaccuracy in the present series. Such analyses before and after 
boiling or extraction have been made by Wardall.*' There is always 
a question in interpreting such figures. The cellulose of which 
vegetables are largely composed is a carbohydrate, but indigestible. 
On the other hand, if starch and soluble carbohydrates are alone 
considered, there is a question whether other substances present may 
not become potential sugar-formers upon digestion. Furthermore it 
is possible that more or less starch inclosed within cellulose may not 
be utilizable. Phloridzinized animals could scarcely furnish fully 
conclusive results. Accordingly an empirical element remains, and 
numerous patients in the present series have had sufficiently severe 
diabetes that extracted vegetables could not be taken without limit. 
The empirical observations have closely agreed with Wardall's chemi- 
cal proof that spinach, celery, and asparagus are the safest for this 
purpose. Cabbage, cauliflower, Brussels sprouts, and onions retain 
enough carbohydrate to cause glycosuria much more readily than the 
three first named. If only 1 per cent absorbable carbohydrate 
should remain, and if a kilogram of the vegetables should be given in a 

" WardaU, R. A., J. Am. Med. Assn.. 1917. box, 1859-1862. See also Joslin's 
text, 2nd edition, p. 261. 



GENERAL PLAN OF TREATMENT 155 

day, it is clear that such carbohydrate content is important for a 
patient whose actual tolerance may be 5 gm. or less. As previously 
mentioned, this state of excessively low tolerance ought not to be 
allowed to persist; but nevertheless carbohydrate should always be 
reckoned as accurately as possible. There is no reason why patients 
whose tolerance is a little greater should not, at least for occasional 
variety, receive higher class vegetables which have been extracted 
to reduce their carbohydrate content; but analyses such as those of 
Wardall will be necessary before they can be used with accuracy. 
What can be done with fruits in this direction will also bear further 
investigation. 

Besides a little carbohydrate, thrice cooked vegetables convey more 
or less salts, and may have some real importance in this respect. 
Blunt and Otis*' found that spinach loses 50 per cent, string beans 
43 per cent, navy beans 39 per cent, peas 36 per cent, and potatoes 
22 per cent, respectively, of their iron in cooking. Salts of potassium 
and heavy metals are also furnished in utilizable form by such vege- 
tables. Courtney, Fales, and Bartlett*' investigated the salt content 
of vegetables boiled so thoroughly as to be comparable to the thrice 
cooked kind. Tables IV and V are reproductions of two of their 
tables. 

This large loss of salts occurred in the first few minutes of boiling; 
for example, spinach boiled only 10 minutes had already lost 42.2 
per cent of its ash; the very prolonged further boiling had relatively 
little effect. These authors confirm the well known marked predomi- 
nance of bases over mineral acids in vegetables, and the assimilable 
character of these bases, which are probably in combination with or- 
ganic acids. It is possible that the very high plasma bicarbonate 
(above rather than below 65 per cent) so often, found in severe cases 
under rigid treatment may be attributable to the vegetable diet. 
With the customary liberal use of vegetables, diabetics should certainly 
suffer no lack as respects quantity, variety, or assimilability of the 
supply of mineral bases. 

** Blunt, K., and Otis, F. A., J. Home Economics, 1917, ix, 213-218; Chem. 
Abstr., 1917, xi, 2124. 

*' Courtney, A. M., Fales, H. L., and Bartlett, F. H., Am. J. Dis. Child.. 
1917, xiv. 34-39. 



156 



CHAPTER n 



For practical purposes, thrice cooked vegetables (generally spinach, 
celery, and asparagus) have been used in limited quantities without 
any food value being reckoned for them. The protein of green vege- 



TABLE IV. 
Content in Gm. of Solids of 100 Gm. of Vegetables Erepared by Boiling. 



Vegetable. 






Spinach. . 
New- 
Zealand 
spinach. 
Young. . . 
carrots 
Onions.. . 
String 

beans. . 
Aspara- 
gus. . . . 
Potatoes. 



90 



30 

30 

45 

ISO 

30 
30 



Solids. 



.30 



4.26 

6.31 
6.82 

5.31 

4.59 
20.51 



Ash. 



1.172 

0.535 

0.408 
0.398 

0.371 

0.370 



CaO 



0.305 

0.145 

0.039 
0.020 

0.070 

0.038 



MgO 



0.035 

0.021 

0.014 
0.013 

0.030 

0.021 



PjOb 



0.123 

0.052 

0.043 
0.067 

0.063 

0.101 



CI 



0.036 

0.000 

0.023 
0.008 

0.045 

0.024 



KsO 



0.238 

0.157 

0.181 
0.186 

0.123 

0.174 



NaaO 



0.068 

0.040 

0.038 
0.010 

0.011 

0.001 



HjSOi 



0.034 



0.016 

0.022 
0.056 



0.025 



FezOj 



0.0090 



0.0154 

0.0070 
0.0026 



Tr. 



0.497 

0.236 

0.108 
0.189 

0.190 

0.283 



i 

3 1 

3.10 



1.48 

0.67 
1.18 

1.19 

1.77 



TABLE v. 
Percentage Lost in Water under Ordinary Boiling Conditions. 



Vegetable. 




3 


JZ 

^ 


9 


61.5 
81.0 
41.6 
10.6 
54.1 
40.1 


2 


o 


<2 


9 

61.1 
77.8 
48.8 

56.3 
Tr. 


57.2 
78.7 
49.9 
31.6 

52.1 


6 

28.2 
50.8 
Tr. 

U 

Tr. 


a; 


Sninacli . , ; 


90 
30 
30 
45 
150 
30 
30 


32.2 
41.3 
37.5 
22.5 
31.8 
27.4 
4.4 


45.2 
72.2 
47.8 
28.0 
43.4 
46.7 


Tr. 

3.6 
28.4 
26.1 
21.4 
26.6 


48.2 
70.2 
34.6 
24.6 
42.7 
34.6 


71.1 
100.0 
57.1 
31.4 
46.8 
46.4 


64.8 
81.9 
47.3 
29.2 

55.2 
49.2 


?3 1 


New Zealand spinach.. . . 
Youner carrots 


22.3 

?? 7 


Onions 


19 8 


Striner beans 


?6 7 


Asnaraffus 


?4 1 


Potatoes 









tables is known to be poorly absorbable.^" Irrespective of any food 
content, diabetics should not be allowed to gorge themselves on these 
extracted vegetables. Those on reasonably liberal diets do not need 
them at all. The allowance for any patient is generally not more 



5" Rubner, M., Berl. klin. Woch., 1916, No. 15. 



GENERAL PLAN OF TREATMENT 157 

than a kilogram per day, and less in proportion as ordinary vegetables 
can be used. Excessive quantities are a useless burden upon both 
the purse and the digestion. 

12. Fruits. — Fruits are the best diabetic desserts, when they can be 
tolerated. Most patients can take at least grape-fruit. Within 
reasonable limits, there is no prejudice against fruits because of their 
carbohydrate being largely in the form of sugar. Neither is there a 
favorable bias because so much of the sugar is levulose, for in the long 
run the actual carbohydrate and total food values are probably the 
determining factors of a diet. Reference must be made to text-books 
for the proportions of different carbohydrates in fruits. The latest 
article that has chanced to come to notice is that of Eofi," showing 
that 52 to 75 per cent of the sugar in apple juice is levulose. 

13. Nuts. — Some nuts resemble prepared diabetic foods in their low 
carbohydrate and high protein and fat content. They must be used 
with corresponding caution. No superior assimilation for nuts or 
other less common foods has been observed. 

14. Unusual Carbohydrates and Abnormal Modes of Administration. — 
Notwithstanding more or less deceptive appearances of assimilation, 
little or no practical value is to be expected from caramel, pentose, 
7-carbon sugars (hediosit), or other unusual food elements. Like- 
wise no hope should be entertained of any special assimilability of 
glucose given by rectum or other abnormal way. It need only be 
noticed that no patient was ever saved from either starvation or coma 
by such means. Confusion will be avoided by recalling the faulty 
theory underlying such attempts. In acidosis, the only lasting benefit 
must come from relief of the metabolism which is breaking down, by 
reducing the diet especially in fat, and not from the introduction of 
strange compounds. In nutrition, the level of total diet and weight 
determined by the actual assimilative power is a limitation which 
cannot be cheated by artificial devices. 

15. Bran Bread or Biscuits. — These are the only form of bread 
substitute used for the type of cases treated in this hospital. In 
milder cases bran can be used in various ways; for example, bread can 
be made of eggs, fat, and bran, or bran can be mixed with ordinary 

" Eoff, J. R., J. Ind. and Eng. Chem., 1917, ix, 587-588. 



158 CHAPTER n 

flour to lower the carbohydrate and food value of the latter. But 
while severely diabetic patients crave some form of bread, they do not 
wish to devote any of their scanty protein or fat to this use. Accord- 
ingly the following recipe was developed for a bran-agar bread 
having no appreciable food value. 

Bran Biscuits. 

Bran, weighed dry 60 gm. 

Agar-agar, powdered 6 " 

Cold water ; 100 cc. 

The bran is tied in cheese-cloth and hung under the cold water tap 
to wash (with stirring or kneading as required) until the water 
runs through clear. The agar is mixed in 100 cc. water (cold) and 
brought to the point of boiling. The agar solution (hot) is then 
added to the washed bran. The mixture is molded into three cakes 
and placed in a pan and when firm and cold baked until dry and crisp. 
Salt may be included in the recipe if desired. The biscuit or muffin 
shape may be chosen, but it has generally been preferred to make thin 
flat pieces like well browned toast. The toasting helps the flavor a 
little, and the dryness facilitates keeping. 

The chief caution is necessary in the choice of bran. Ordinary bran 
flours or breakfast foods are high in carbohydrates. Some kinds of 
cheap bran contain middlings or other carbohydrate admixture. It is 
possible to buy purified bran, such as Kellogg's. But the bran 
ordinarily used for feeding cattle, which on inspection is seen to con- 
sist of coarse flakes of the outermost hull of the wheat, is obtain- 
able very cheaply at feed stores, and is perfectly satisfactory when 
washed under the cold water tap for half an hour or more as above 
described. 

Some patients like these tasteless bran rusks at once; others either 
accept or enjoy them after becoming used to them. They are best 
served hot, like toast, with butter, bacon fat, a fried egg, or even 
soup, to give them flavor. Besides contributing bulk, like the vege- 
tables, the bran is stiU more active in favoring catharsis, and since its 
introduction the traditional constipation of diabetic patients has 
been almost unknown in this hospital. A few individuals cannot 
take the bran; in others sometimes indigestion or diarrhea limits the 



GENERAL PLAN OF TREATMENT 159 

amount. On general principles, an inert substance should not be 
taken to excess, and accordingly the allowance is generally no more 
than one or two of the above cakes at each meal. 

Bran has never been responsible for glycosuria in this hospital, 
and is probably not digested to any important extent. The chemis- 
try of bran, especially from the standpoint of digestion, is not thor- 
oughly known. It is poor in cellulose (2 to 4 per cent in most analy- 
ses), and from its richness in protein and amides, phytin and other 
complex compounds, might supply the body with much nitrogen and 
phosphorus if digestible. Guareschi^^ states that bran milled to an 
impalpable powder is 91 to 92 per cent digestible, and emphasizes its 
value for food and for vitamines. The fine milling therefore defeats 
the purpose for which bran is used in diabetes. 

16. Proprietary Foods. — So called "diabetic" and "gluten" prepa- 
rations have largely fallen into disrepute because of the rankly fraudu- 
lent character of so many of them. It is still very common for pa- 
tients to announce that as soon as diabetes was discovered they be- 
gan to eat gluten bread, with or without a doctor's orders; but knowl- 
edge on the subject is increasing, and it is becoming generally known 
that a physician should at least never order such a food without 
specifying a reliable brand. 

The medical profession is indebted to Professor John P. Street for 
the most complete analyses of diabetic foods. The results are obtain- 
able in the publications of the Connecticut Agricultural Experi- 
ment Station, especially the report for 1913, Part 1, with added analy- 
ses in the report for 1914, Part 5, and the report for 1915, Part 5. 
These data are the best basis for the choice of a diabetic preparation. 
With improved technical methods, the best brands have been brought 
to a high state of perfection from the standpoint of carbohydrate- 
ireedom and agreeable taste. Without invidious distinctions, men- 
tion may be made of American made examples of the three principal 
classes of such foods; viz., gluten flour, which is manufactured in high 
purity by Hermann Barker, Somerville, Mass.; casein flour and 
muflSns, as prepared by Lister Brothers, 110 West 40th Street, New 

^^ Cf. Guareschi, I., Ind. ckim., min. e metal.; 1917, iv, 97-103; Chem. Abstr., 
1917, xi, 2124. Holmes (Holmes, A. D., U. S. Dept. Agric, Bull. 751, 1919) has 
obtained a coeflScient of digestibility of only 45 per cent for finely milled bran. 



160 



CHAPTER n 



York City; and soy bean flour, one brand of which is made by the 
Cereo Company, Tappan, New York, while the most extensive use 
of soy beans by diabetics at present is in the form of the "Hepco" 
flour, dodgers, etc., made by the Waukesha Health Products Com- 
pany, Waukesha, Wisconsin. For complete hsts and analyses of such 
foods, reference must be made to Street's reports or Joslin's text-book. 

The essential objection to all such bread substitutes is that in ab- 
sence of carbohydrate, they have necessarily been composed of pro- 
tein and fat, and thus have represented highly concentrated forms of 
food. Both physicians and patients have often viewed these breads 
as harmless, or even commendable by reason of their high protein and 
food value. The great amount of protein and calories that can be sO' 
easily and inadvertently consumed in this way is capable of tre- 
mendous damage. Janney^' has pointed out that the potential car- 
bohydrate represented in the protein often exceeds the total carbohy- 
drate of ordinary bread. It is necessary to warn strongly against this- 
indiscriminate misuse of even the best preparations, in which the 
manufacturer is not to blame. There is no objection to making upi 
as large a proportion of the diet as desired from these flours, provided 
the total diet is accurately reckoned and restricted as usual. For cases, 
of the grade of severity treated in this hospital, the use of such prepa- 
rations has been abandoned, simply because the patients prefer to 
take their protein and fat in meat, eggs, bacon, butter, etc., rather 
than in flour or bread. 

Because of the very limited quantity of these concentrated foods- 
which can safely be included in any diet, and because of the danger- 
ous ease with which patients can be tempted to overstep their real 
tolerance by taking only a small quantity in excess, the manufacturers- 
of some of the better brands are moving in the direction of reducing; 
the undesirably high food value by the introduction of some indigesti- 
ble substitute for carbohydrate. A non-utilizable flour might be 
employed in three ways; first, to dilute ordinary flour for mild cases, 
so as to reduce the carbohydrate and food value of wheat, corn, or 
other bread; second, to dilute the special diabetic flours, so as to make 
them permissible more often and in larger quantities, Fhile at the same- 

" Janney, N. W., Arch. Int. Med., 1916, xviii, 584-605. 



GENERAL PLAN OF TREATMENT 161 

time probably reducing their cost; third, for making an entirely non- 
nutritious bread substitute, perhaps finer and more agreeable than the 
bran bread. An extreme illustration of the feasibility of the use of a 
non-nutritious flour can be gained by making a batter with egg, spices, 
and impalpable talcum powder, and frying it crisp. This will appear 
more satisfying than the egg fried alone. While talcum is inert and 
harmless, it is scarcely to be recommended for eating, and a non- 
utilizable flour for practical use is most likely to be found in the 
vegetable kingdom, probably in some form of cellulose or other 
polysaccharide.^* Ridicule or opposition may be aroused by sug- 
gestions of flour from cotton, peanut-shells, corn-pith, etc., and the 
technical difficulties also have thus far baffled manufacturers. The 
German experience in the recent war, that large quantities of wood 
flour may cause intestinal disturbance, was confirmed in one short test 
with diabetics; but the long experience with bran and shorter trials of 
other indigestible substances have shown that the prudent use of these 
is safe and practicable. Critics should bear in mind the following 
facts: first, it is generally conceded that the food of civilized man is 
overconcentrated, frequently excessive, and subject to improvement 
by an admixture of indigestible material, as in coarse vegetables; 
second, the diabetic flours which it is proposed to dilute are dry pro- 
tein-fat powders representing an unnaturally concentrated form of 
food; third, diabetics must be more closely limited in their total food 
intake than normal persons, and yet they have the usual, even if not 
an excessive craving both for bread and for bulk. 

D. General Scheme and Specimen Diets. 

Two general plans, are possible for diabetic diets. The one which 
has been customary in the past has aimed to give the patient substi- 
tutes as nearly as possible resembling the accustomed dishes which 
he must forego. Accordingly, diabetic cook-books have been fflled 

^* Concerning some indigestible carbohydrates, see Mendel, L. B., Ceniralbl. 
ges. Physiol, u. Path. Stoffwechs., 1908, iii, 641-654. Mendel, L. B., and Swartz, 
M. D., Am. J. Med. Sc, 1910, cxxxix, 422^26. Swartz, M. D., Tr. Connecticut 
Acad. Arts, and Sci., 1911, xvi, 247. Concerning the German experience with 
wood flour, see Salomon, H., Wien. med. Woch., Dec. 15, 1917 (favorable), and 
Neumann, R. O., Vrtljschr. gerichll. Med., 3rd edition, li, pt. ii, (unfavorable). 



162 CHAPTER II 

with composite recipes, carbohydrate-free puddings, saccharine sweet- 
ening, imitation milk, and a host of similar artifices. The most con- 
venient way to manage such a diet accurately is to weigh out the 
day's allowance of eggs, fat, etc., in the morning and use for cooking 
the different meals as required. It may be urged that habits of food 
are hard to break, and that a diabetic should not be deprived of 
gustatory pleasure xmnecessarily. It may be objected on the other 
hand that such diets tantalize and tempt more than they satisfy; 
that saccharine keeps aUve the taste for sugar, that the liabiUty to 
carelessness is increased, and that a patient does best to face squarely 
the fact of his diabetes and the necessary restrictions, and to resolve 
to eat to hve rather than Uve to eat, especially since care in diet is the 
means whereby all the other pleasures and advantages of the world 
are opened to him in fullest measure. 

It is generally beheved that the plainest and simplest diets are the 
most wholesome for mankind in general. It has therefore been consid- 
ered inadvisable to take such great pains to depart from such a diet 
for diabetics. Not only is simpHcity highly important for accuracy, 
fidehty, convenience, economy, and healthful habits, but in the long 
run the simple diet has proved the most satisfying and the least irk- 
some. The patient begins such a Spartan regime immediately after 
his initial fast in the hospital, when anything tastes good, and by the 
time he leaves the hospital his new habit of diet is estabhshed. With 
simple menus and a balanced ration, diabetics are free from abnormal 
cravings, and natural himger on reduced diets is also easier to appease. 

Simplicity does not mean unpleasantness to sight or taste. Here the 
skill of the diet nurse or cook comes into play. The refinement of 
the table service, even though not expensive, has its esthetic value. 
Salads and other simple dishes can be made attractive in appearance. 
A single egg can loom surprisingly large to the eye if beaten into a 
fluffy omelette or souffle. Variety in cooking and combining the 
same foods varies them to the taste. Vegetables offer variety in soups, 
and the different ways of serving meat are well known. Eggs, bacon 
grease, meat, or the juice from meat give variety and taste to thrice 
cooked vegetables, and even to bran muffins. There is no inherent 
objection to condiments or spices, but these, except salt, have been 
little used, since the diabetic appetite generally needs no stimulation, 



GENERAL PLAN OF TEEATMENT 163 

and the simple taste of plain foods is sufl&ciently appreciated. Coffee 
lovers generally learn readily to like their drink black, without sac- 
charine. A little fruit is a sufficient dessert in most cases. The de- 
sire for cake, puddings, and other luxuries is discouraged by disuse. 
Exceptions have been made only in some extremely severe cases on 
minimal diets, since small treats mean so much to these patients. 
Agar jelly, ices, sherbets, etc., can be flavored with saccharine, coffee, 
wine, brandy, fruit juices, or sugar-free caramel (the quantities re- 
quired being very small). Likewise agar with soup or beef extract 
makes an agreeable meat jelly. Such tricks often eke out a low diet 
or reheve a hard fast-day in the worst cases; but the better fed class 
of patients do not need them. 

The physician who cannot calculate diets to suit his individual cases, 
but is dependent upon text-book menus, will not be able to substi- 
tute celery or spinach when one or the other is disliked, and will oc- 
casionally meet patients who know more about diets than he. Any- 
body who has a list of food values and can use the decimal system can 
easily make up the simple diets required by diabetics. The unwise 
complexity of dishes in the past has doubtless been largely respon- 
sible for the unfortunate helplessness of so many physicians in this 
regard. The use of the metric system is not a difficulty but a great 
convenience, and it can be learned in a few minutes by those un- 
accustomed to it. Though the energy value of carbohydrate and pro- 
tein is 4.1 calories per gm., and of fat 9.3 calories per gm., it is suffi- 
ciently accurate for ordinary purposes to reckon them as 4 and 9 
calories respectively.^^ One elementary example should make the 
method clear. . 

Suppose that a patient's weight is 50 kilograms, that his tolerance 
in the carbohydrate test was 180 gm., and that he is to be given a 
mixed diet containing one-sixth of this maximal carbohydrate toler- 
ance, together with 1.5 gm. protein and 30 calories per kilogram. 

^^Food chemists are well aware of the technical considerations which make 
absolute exactness impossible in the ordinary reckoning of a diet. A practical 
point is that the number of calories obtained by multiplying the total grams of 
protein, carbohydrate, and fat by the proper factors, and the number found by 
adding up the calories given in food tables for the individual meats, vegetables, 
and other foods served, are seldom identical. Either method is permissible. 



164 



CHAPTER n 



One-sixth of the carbohydrate tolerance of 180 gm. is 30 gm. Any 
desired vegetables are selected from food tables to make up this total 
of 30 gm. for the day, and divided between the meals at will. The 
protein, fat, and calories in the vegetables chosen must be reckoned, 
which will give a result such as shown in Table VI. 



TABLE VI. 










Food. 


Carbohy- 
drate. 


Protein. 


Fat. 




Breakfast. 

Canned asparagus 


gm. 
150 

50 

37 
148 
142 

50 

150 

86 


gm. 

4.2 

1.7 
1.1 

5.0 

5.5 

1.7 
5.9 
5.0 


gm. 
2.3 

0.7 
0.5 

2.2 

1.1 

0.7 
1.2 
1.4 


gm. 

0.2 

0.2 

0.1 
0.5 

0.2 
0.6 
0.6 




Dinner. 

Lettuce 




Celery 




Canned Brussels sprouts 




Raw tomato 




Supper. 

Lettuce 




Raw tomato 




Cauliflower 








Gm 


30.0 
120.0 


10.0 
41.0 


2.4 
22.3 




Calories 


18"? 







TABLE VII. 



Food. 


Protein. 


Fat. 




Breakfast. 

Eggs 


gm. 

100 
50 

57 
25 

100 
50 


gm. 

14.8 
5.0 

18.3 
6.5 

14.8 
5.0 


gm. 

10.6 
33.6 

2.5 
7.9 

10.6 
33.6 




Bacon 




Dinner. 

Roast chicken 




Cream cheese 




Supper. 

Eggs 




Bacon 








Gm 


64.6 
258.0 


98.8 
899.0 




Calories 


1157.0 





GENERAL PLAN OF TREATMENT 



165 



Taking up next the protein allowance, this, at l.S gm. per kilogram 
for a weight of SO kilograms, will amount to 75 gm. of protein. Since 
10.4 gm. of protein is contained in the vegetables already chosen, 
this leaves 64.6 gm. yet to be supplied for the day (Table VII). 



TABLE 


VIII. 












■ 

Food. 


Carbo- 
hydrate. 


Protein. 


Fat. 




Bueakfast. 

Eess 


gm, 

100 

50 

ISO 

5 

57 
10 
50 
37 
148 
142 
25 

100 

50 

9 

50 

150 
86 


cc. 

150 
150 

150 
150 

150 
150 


4.2 

1.7 

1.1 

5.0 

5.5 

1.7 
5.9 
5.0 


gm. 

14.8 
5.0 
2.3 

18.3 

0.7 
0.5 
2.2 
1.1 
6.5 

14.8 
5.0 

0.7 
1.2 
1.4 


gm. 

10.6 

33.6 

0.2 

4.1 

2.5 
8.2 
0.2 

0.1 

0.5 
7.9 

10.6 
33.6 
7.4 
0.2 
0.6 
0.6 




Bacon 




Canned asparagus 




Butter 




Bran biscuits (2) 




Coffee 




Clear soup 




Dinner. 

Roast chicken 




Butter . 




Lettuce 




Celery 




Canned Brussels sprouts 




Raw tomato 




Cream cheese 




Bran biscuits (2) 




Kaffee Hag. 




Clear soup 




Supper. 

Eggs 




Bacon 




Butter . . 




Letituce 




Raw tomato 




Cauliflower 




Bran biscuits (2) 




Kaffee Hag 




Clear soup 








Gm 


30.0 
120.0 


75.0 
300.0 


120.6 
1085.0 






1505 







A ration of 30 calories per kilogram for a weight of 50 kilograms 
means 1500 calories for the day. Since the foods chosen for carbo- 
hydrate and those chosen for protein together represent 180+1157 = 



166 



CHAPTER n 



1337 calories, this leaves 163 calories yet to be supplied in the fonn of 
fat. It is now necessary to divide the 163 calories by 9, thus showing 
18 gm. as the quantity of fat needed. This could be supplied by 18 
gm. of olive oil, or 24 gm. of butter, or the equivalent in any other 
fat. The total diet for the day is shown in Table VIII. 

The specimen diets in Tables IX to XV are given as suggestions. 
In them, the factors 4.1 and 9.3 are used, as customary in this 
hospital. 



TABLE rx. 

Carbohydrate Tolerance Test. 

A Day's Diet with 30 Gm. Carbohydrate. 



Food. 



Breakfast. 

Canned asparagus 

Coffee 

Clear soup 

Dinner. 

Lettuce 

Celery 

Canned Brussels sprouts. 

Canned okra 

Clear soup 

Kaffee Hag. 

Supper. 

Lettuce 

Raw tomato 

Spinach 

Canned okra 

Clear soup 

Kaffee Hag. 



m 

Calories. 



ISO 



25 

75 

150 

65 



25 
ISO 
200 

66 



150 
150 



150 
150 



150 
150 



FFotein. 



2.3 



0.4 
1.0 
2.2 
0.4 



0.4 
1.2 
4.2 
0.5 



12.5 
51.0 



Fat. 



0.2 



0.1 
0.1 

o:o5 



0.1 
0.6 
1.0 
0.05 



2.2 
20.0 



Carbo- 
hydrate. 



4.2 



0.9 
2.2 
5.1 
2.3 



0.9 
5.9 
6.2 
2.4 



30.0 
123.0 



194 



GENERAL PLAN OF TREATMENT 



167 



TABLE X. 

Carbohydrate Tolerance Test. 
A Day's Diet with 100 Gm. Carbohydrate. 



Food. 



Breakfast. 

Canned asparagus.. 

Beets 

Celery 

Clear soup 

Coffee 

Dinner. 

Lettuce 

Raw tomato 

Carrots 

Cabbage 

Clear soup 

Canned okra 

Celery 

Kaffee Hag 

Supper. 

Lettuce 

Celery. 

Turnips 

Clear soup 

Canned okra 

Raw tomato 

KaSee Hag 



gm. 

ISO 

208 

SO 



100 
203 
218 
172 

90 
SO 



SO 
100 
230 

90 

S4 



ISO 
ISO 



150 



ISO 



ISO 



150 



Gm 

Calories. 



Protein. 



gm. 

2.3 
3.2 
0.7 



1.3 

1.6 

2.3 
3.5 

0.7 
0.6 



1.5 
1.4 
3.2 

0.6 
0.4 



23.3 
95.5 



Fat. 



Carbo- 
hydrate. 



gm. 

0.2 
0.2 
0.05 



0.4 
0.8 
0.8 
0.6 

0.1 
0.05 



0.2 
0.1 
0.4 

0.1 
0.2 



4.3 
45.6 



gm. 

4.2 

20.0 

1.5 



3.3 

7.9 

20.0 

10.0 

3.2 
1.5 



1.7 

3.0 

20.0 

3.2 
2.1 



101.6 
416.6 



557.7 



168 



CHAPTER n 



TABLE XI. 

Carbohydrate Tolerance Test. 
A Day's Diet with 250 Gm. Carbohydrate. 



Food. 



Breakfast. 

Orange 

Canned peas 

Carrots 

Rice 

Coffee 

Clear soup 

Dinner. 

Grapefruit 

Lettuce 

Canned asparagus.. 

Potato 

Canned lima beans. 

Turnips 

Kaffee Hag 

Clear soup 

Supper. 

Apple 

Lettuce 

Raw tomato 

Parsnips 

Onions 

Kaffee Hag 

Clear soup 



104 

204 

218 

39 



200 
100 
ISO 
168 
205 
230 



120 
100 
64 
122 
303 



150 
150 



150 
150 



150 
150 



Gm 

Calories . 



Protein, 



gm. 

0.8 

7.2 
2.3 
3.0 



1.3 
2.3 
2.0 
8.2 
3.2 



0.6i 
1.3 
0.5 
2.0 
5.1 



Fat. 



39.8 
159.1 



gm. 

0.6 
0.4 
0.8 
0.1 



0.4 
0.2 
0.1 
0.6 
0.4 



0.6 
0.4 
0.2 
0.6 
1.2 



6.6 
61.4 



Carbo- 
hydrate. 



gm. 

10.0 
20.0 
20.0 
30.0 



10.0 
3.3 
4.2 
30.0 
30.0 
20.0 



20.0 

3.3 

2.5 

19.6 

30.0 



252.9 
1025.0 



1246 



GENERAL PLAN OF TREATMENT 



169 



TABLE XII. 
Exclusive Protein Diet, as Sometimes Used for Bringing Down Blood Sugar. 



Food. 



Breakfast. 

Egg white 

Celery T.C.* 

Spinach " 

Coffee 

Clear soup 

Bran biscuits (2) 

Dinner. 

Flounder 

Sauerkraut T. C 

Brussels sprouts T. C. 

Bran biscuits (2) 

Coffee. 

Soup 

Supper. 

Roast chicken 

CauHflowerT. C 

Asparagus " 

Bran biscuits (2) 

Kaffee Hag 

Soup 



Gm 

Calories. 



gm. 

162 
200 
100 



216 
200 
200 



78 
200 
100 



150 
ISO 



150 
150 



150 
150 



Protein. 



20.0 



30.0 



25. 



75.0 
307.0 



Fat 



0.3 



1.2 



3.4 



4.9 
45.0 



352 



' T. C. indicates thrice cooked. 



170 



CHAPTER n 



TABLE Xni. 

Example of a Low Maintetiance Diet for a Case of Extreme Severity; Body Weight 

30 to 40 Kilograms. 



Food. 



Bieakfast. 

Eggs 

Bacon 

Butter. 

Celery T.C 

Bran biscuits (2).. , 

Coffee 

Clear soup 

Dinner. 

Flounder. 

Butter 

Lettuce 

Raw tomato 

Cauliflower T. C. . 

Asparagus " . . 

Bran biscuits (2)... 

KaffeeHag 

Clear soup 

Sup per. 

Eggs 

Cream cheese 

Butter. 

Lettuce 

Canned asparagus.. 

Spinach T.C 

Cabbage " 

Bran biscuits (2) . . 

Kaffee Hag 

Clear soup 



Gm 

Calories. 



gm. 

100 

50 

7 

200 



72 

7 

25 

34 

200 

200 



100 

13 

7 

25 

71 

200 

200 



150 
150 



Protein. 



150 
150 



150 
150 



14.9 
5.0 



10.0 

0.4 
0.2 



14.9 
3.3 

0.4 
1.0 



50.1 
205.0 



Fat. 



gm. 

10.6 

33.6 

5.8 



0.4 
5.8 
0.1 
0.1 



Carbo- 
hydrate. 



10.6 
4.1 
5.8 
0.1 



77.0 
716.1 



gm. 



0.9 

1.3 



0.9 
2.0 



5.1 
21.0 



942 



GENERAL PLAN OF TREATMENT 



171 



TABLE XIV. 

Specimen Diet of a Child Aged 3 or 4 Years {Patient No. 73), with Extremely Severe 
Diabetes; Weight 9 Kilograms. 



Food. 



Protein, 



Fat. 



Carbo- 
hydrate, 



7:30 a.m. 

Egg 

Milk 

Butter. 

Asparagus T. C... 

Clear soup. 

Bran biscuit (1) 

11:00 a.m. 

Egg. 

Milk 

Canned asparagus.. 

Butter. 

Clear soup. 

1:00 p.m. 

Milk 

Butter. 

Raw tomato 

Clear soup 

Bran biscuit (1).. . . 
3:00 p.m. 

Milk 

Clear soup 

5:30 p.m. 

Egg. 

Milk 

Butter. 

Celery. 

Bran biscuit (1).... 

Clear soup 



SO 
25 

7 
75 



50 

25 

107 

6 



50 

6 

60 



25 



50 
25 

7 
75 



100 



100 



100 



100 



100 



Gm 

Calories. 



(m. 

7.4 
0.8 



7.4 
0.8 
1.6 



1.6 
0.5 

0.8 



7.4 
0.8 

1.0 



30.1 
125.0 



gm. 

5.3 
1.0 
5.8 



5.3 
1.0 
0.1 
4.9 



2.0 
4.9 
0.2 



1.0 



5.3 
1.0 

5.8 



43.6 
405.0 



1.3 



1.3 
3.0 



2.5 
2.3 

1.3 

1.3 

2.2 



15.2 
62.3 



591 



172 



CHAPTER n 



TABLE XV. 

Example of a Maintenance Diet, Showing the Substitutions Indicated for Patients Who 

Cannot Perform Calculations for Themselves. 

Protein 90 gm. Carbohydrate 50 gm. Calories 2000. 



Food. 


1 


i 


V 

1 




Substitutes. 




gm. 


cc. 


gm. 


gm. 


gm. 




Breakfast. 
Eggs 


100 
50 
13 

ISO 

96 

20 
•25 
150 

295 

100 

19 

100 
SO 
20 
25 
75 
323 
172 
19 


ISO 
LSO 

150 
150 

ISO 
150 


14.8 
5.0 

2.3 

22.3 

0.4 
1.2 

4.4 
1.6 
4.9 

14.8 
5.0 

0.4 
1.0 
6.7 
3.5 
4.9 


10.6 

33.6 

10.7 

0.2 

1.5 

16.5 
0.1 
0.6 

0.3 
0.8 
6.0 

10.6 

33.6 

16.5 

0.1 

1.6 
0.6 
6.0 


4.2 

0.8 
5.9 

10.0 
6.0 

0.8 

2.2 

10.0 

10.0 






Bacon 




Butter 




Canned asparagus. 
Bran biscuit (2)... 
Coffee 


Fresh asparagus 124 gm. (in place of canned). 


Clear soup 

Dinner. 

Roast beef 

Butter. 


Roast chicken 69 gm.less butter 2 gm. 

Flounder 160 gm. 

Veal 79 gm. 

Roast Lamb 113 gm. less butter IS gm. 


(in 

place of 

roast 

beef). 




Radishes 25 gm. (in place of lettuce). 


Raw tomato 

Canned Brussels 

sprouts 

Cauliflower 

Cream cheese 

Bran biscuits (2) . . 

Kaffee Hag 

Clear soup 

Supper. 


Beets 61 gm. (in place of tomato). 

Carrots 109 gm. (in place of Brussels sprouts). 

Celery 200 gm. (in place of cauliflower). 


Bacon 




Butter 




Lettuce 




Celery 


Dill pickle 82 gm. (in place of celery). 


Spinach 


String beans 107 gm. (in place of spinach). 


Cabbage 


Turnips 115 gm. (in place of cabbage). 


Cream cheese 

Bran biscuits (2).. 

Kaffee Hag 

Clear soup 


Sauerkraut 228 gm. (in place of cabbage). 


Gm 


93.2 
369.0 


149.9 
1394.1 


50.0 
205.0 






Calories 


1968 







ClSRBiGHTDRATE 




GENERAL PLAN OF TREATMENT 173 

E. Food Tables. 

The accompanying graphic charts illustrate a short method for 
approximating food values, which can be made both more convenient 
and more accurate if enlarged and used for wall charts. The abscissa 
represent grams of foodstuffs; the ordinates show both grams and cal- 
ories of carbohydrate, protein, and fat respectively. Thus, taking 
the number 50 at the bottom of the carbohydrate chart, and follow- 
ing the line up to where it cuts the line for sauerkraut, it is seen at a 
glance that 50 gm. of sauerkraut contain 2 gm. or 8.2 calories of car- 
bohydrate. Conversely, if it is desired to select food containing 5 gm., 
of carbohydrate, one may start at the number 5 on the left of the chart 
and by following it across may see that this quantity is represented 
in about 51 gm. of onions, about 67 gm. of blackberries, about 100 
gm. of either grapefruit or milk, etc. The same method is used in 
finding protein and fat values in the other charts. 

The food values in Tables XVI to XIX are taken almost entirely 
from the tables of Bryant and Atwater, Bulletin 28, Department of 
Agriculture, Bureau of Experiment Stations, Washington, D. C. Simi- 
lar tables, along with analyses of cooked foods, etc., are given in the 
book on "Food Values," by Edwin A. Locke, Appleton and Company, 
1914. 

Abundant data for diabetic needs are contained in Joslin's text- 
book. The list given in Chart 1 and Tables XVI to XIX is not 
extensive, but yet contains nearly everything found necessary for 
the diets in this hospital. Copies are supplied to patients for 
reckoning their diets at home. 



174 



CHAPTER n 



TABLE XVI. 

Meat and Fish* 



Edible portion. 


Protein. 


Fat. 


Carbohy- 
drate. 


Meats. 


fer cent 

10.0 
20.5 
20.8 
22.8 
20.2 
19.5 
19.7 
19.1 
21.0 

18.8 
19.0 
15.8 
13.9 
18.3 
20.6 
20.9 
18.6 


per cent 

67.2 

6.4 

5.8 

1.8 

20.8 

14.4 

19.0 

12.4 

3.6 

0.5 
1.2 
0.4 
0.6 
5.2 
12.8 
3.8 
9.5 


per cent 



Beef sirloin verv lea,ii 





" round " " 




















" loin . ... 





Lamb 





Veal 





Fresh fish. 

Sea bass 





Blue fish 





Cod, fresh 





FlouiMier 





Halibut 










Shad roe 


2.6 


" whole : 










*Uncooked values. 



GElsTERAL PLAN OF TREATMENT 



175 



TABLE XVII. 
Vegetables, in Order of Their Carbohydrate Content from Lowest to Highest. 



Edible portion. 



*Mushrooms (range 2 to 18 per cent) . 

Cucumbers, fresh 

Asparagus, canned 

Celery, fresh 

Spinach " 

Asparagus " 

Lettuce " ! 

Brussels sprouts, canned 

Rhubarb, fresh 

Tomatoes " 

" canned 

Brussels sprouts, fresh 

Sauerkraut 

Artichokes, canned. 

Leeks 

Eggplant, fresh 

Pumpkin " 

Cucumber pickles 

Kohlrabi, fresh 

Cabbage 

Cauliflower 

Radishes 

Turnips 

Carrots 

Beans, string, fresh 

Beets, fresh 

Peas, green, canned 

Onions, fresh 

Squash " 

Lima beans, canned 

Com, green, fresh 

Peas " " 

Parsnip, fresh 

Artichoke " 

Potatoes " 

Lima beans " 



Protein. 


Fat. 


Carbohy- 
drate. 


per cent 


per cent 


per cent 


(3.5) 


(0.4) 


(6.0) 


0.8 


0.2 


2.5 


l.S 


0.1 


2.8 


1.4 


0.1 


3.0 


2.1 


0.5 


3.1 


1.8 


0.2 


3.3 


1.3 


0.4 


3.3 


1.5 


0.1 


3.4 


0.6 


0.7 


3.6 


0.8 


0.4 


3.9 


1.2 


0.2 


4.0 


4.7 


1.1 


4.3 


1.5 


0.8 


4:A 


0.8 


0.2 


5.0 


1.2 


0.5 


5.8 


1.2 


0.3 


5.1 


1.0 


0.1 


5.2 


0.5 


0.5 


5.4 


2.0 


0.1 


5.5 


2.1 


0.4 


5.8 


1.6 


0.8 


6.0 


1.4 


0.1 


6.6 


1.4 


0.2 


8.7 


1.4 


0.4 


9.2 


2.2 


0.4 


9.4 


1.6 


0.1 


9.6 


3.6 


0.2 


9.8 


1.7 


0.4 


9.9 


1.6 


0.6 


10.4 


4.0 


0.3 


14.0 


2.8 


1.1 


14.1 


4.4 


0.5 


16.1 


1.7 


0.6 


16.1 


2.6 


0.2 


16.7 


2.1 


0.1 


18.0 


7.1 


0.7 


22.0 



* Wardall, (/. Am. Med. Assn., 1917, kix, 1859-1862) pointed out that the 
carbohydrate of ordinary mushrooms is in some non-extractable form, and the 
nitrogen according to Mendel's analyses is likewise in non-protein, non-utilizable 
compounds. The figures in the above table are therefore placed in parentheses 
to indicate their misleading nature. It would appear that ordinary mushrooms 
may be reckoned as having no appreciable food value, and that they therefore 
mav be a welcome feature of the diabetic diet. 



176 



CHAPTER II 



TABLE XVin. 

Fruits, In Order of Their Carbohydrate Content, from Lowest to Highest. 



Edible portion. 


Protein. 


Fat. 


Carbohy- 
drate. 


Grapefruit 


per cent 

0.3 
1.0 
0.9 
0.6 
0.7 
0.4 
0.8 

0.5 
1.0 
1.0 
1.1 
0.6 
0.5 


per cent 

0.1 
0.1 
0.2 

0.1 
0.3 
0.6 

0.7 
1.0 
1.3 

0.8 
0.5 


per cent 
5.0 


Watermelon. 


6.5 


Strawberries 


6.8 


Blackberries 


7.5 


Muskmelon 


9.3 


Peaches 


9.4 


Pineapple 


9.7 


Orange 


9.7 


Lemon juice 


9.8 


Cranberries 


10.1 


Raspberries 


12.6 


Grapes 


13.3 


Apricots 


13.4 


Pears 


14.2 


Apples 


16.6 







TABLE XIX. 
Dairy Products. 



Edible portion. 


Protein. 


Fat. 


Carbohy- 
drate. 


Eggs. 


per cent 
14.9 

3.3 
3.0 
5.97 
2.5 

37.1 
28.2 
26.9 
25.9 
28.8 
29.6 
23.0 
15.4 
27.6 
15.9 
18.7 
22.6 


per cent 

10.6 

82.4 
4.0 
O.S 
7.36 

18.5 

17.7 
32.0 
31.6 
31.7 
36.2 
38.3 
29.4 
21.7 
34.9 
21.0 
27.4 
29.5 


per cent 


Butter 




Whole milk 


5 


Buttermilk 


4 8 


Whiting's milk* 




Cream, average 


4 5 


Cheese. 

Dutch 




Cheddar 




Cheshire 




Cream 




American, pale 




" red 




Limburger 


4 


Boudon 


0.7 
1 ^ 


Swiss 


Brie 


1 4 


Neufchatel 


1 5 


Roquefort 


1.8 





' D. Whiting and Sons, 570 Rutherford Avenue, Boston. Mass. 



CHAPTER III. 
Case Records. 

Seventy-six cases have been selected for publication, for reasons 
stated in Chapter VII. Graphic charts have been chosen as the 
clearest and most compact means of presenting the large mass of 
clinical and chemical data. With a little attention to the key shown 
on all the charts, it is beheved that they will be found simple and 
self-explanatory. The curves of ammonia, total acetone, and total 
acidity of the urine have been plotted as cubic centimeters of deci- 
normal solution, for the sake of chemical calculations and comparisons. 
This plan will doubtless prove somewhat confusing to many clinicians, 
but the tables and summaries in the case histories express the results 
in grams. The written history of each case is supposed to be followed 
in conjunction with the graphic chart, and reference from one to the 
other will be necessary to make both plain. 

Table I is a general summary of the entire series. The data mostly 
tell their own story. Further details, of the age incidence, complica- 
tions, results of treatment, etc., are shown in Chapter VII. The 
etiologic relations are discussed in Chapter VIII. 

CASE NO. 1, 

Female, unmarried, age 28 yrs. American; no occupation. Admitted Feb. 
24, 1914. 

Family History. — Grandparents lived to healthy old age. Father living, aged 
58, has arterial hjT)ertension, neuralgia, and tendency to melancholia. Mother 
died at birth of this patient. An uncle died of tuberculosis. One fuU brother of 
patient died at 16 of appendicitis. One half-sister aged 22 has nephritis, conse- 
quent upon scarlatina. 

Past History. — No childhood diseases except measles and one dysenteric attack. 
Normal menstruation began at 13. Patient graduated from university at 20. 
She has had a nervous, overactive life with late hours and irregular eating. Was 
considered remarkable among her family and friends for the amount of candy 
and sweets she consumed. Normal weight 115 to 120 pounds. July, 1912, pa- 
tient's fianc6 died of accidental poisoning. Patient became melancholic and kept 

177 



178 CHAPTER in 

more to herself, while eating still more candy than usual. She and her parents 
were inclined to attribute onset of diabetes to grief. 

Present Illness.— In Jan., 1913, abnormal thirst was first noted. In Mar., 
pruritus vulvae. In May, menstruation stopped and remained absent. Hair 
fell out and is still thin. July, 1913, diagnosis of diabetes was made and routine 
diet prescribed, which was taken in huge quantities owing to polyphagia. Symp- 
toms persisted and increased till Jan. 4, 1914, when she began treatment at a 
well known diabetic sanitarium. Qualitative and quantitative restriction of the 
diet, oat cures, vegetable days, etc., failed to clear up the condition. She was 
then transferred to this hospital, and arrived tired but not dangerously exhausted 
after a journey of 32 hours. 

Physical Examination.— Height 165.6 cm. Weight 40.1 kg. Marked emacia- 
tion, face flushed and slightly pufiEy, drowsy and slightly alcoholic expression. 
No enlargement of tonsils or lymph glands. Blood pressure 103 systolic, 80 dias- 
tolic. Examination otherwise negative. 

Treatment: — This was the first patient for the proposed treatment, and she was 
qloser to coma than was desired for a first trial. Accordingly the attempt was 
made to be conservative. She was put to bed and a light supper ordered of two 
eggs, a slice of toast, and a cup of milk-cocoa. Breakfast the next morning in- 
cluded oatmeal; the rest of the diet was light and included vegetables and potato 
in limited quantities. Notice should be taken that the blank food space in the 
graphic chart for Feb. 24 to 25 does not represent fasting, but exact reckoning 
of the diet was impossible because cooking and other arrangements were not in 
readiness. At the same time liquids were forced to 6 or 7 liters per day, and alkali 
was given as stated under acidosis below. As coma was imminent, there was no 
choice but to take the chance of beginning the proposed treatment. Therefore 
Feb. 27 was a vegetable day with 45 gm. carbohydrate and 530 calories. Feb. 28 
was a fast-day with nothing but 200 calories of whisky. Marked improvement was 
evident in the urine, which became alkaline, but there was a large bicarbonate 
edema as illustrated by the weight curve, and weakness and drowsiness con- 
tinued. Then, in order to guard against any supposed dangers of fasting, 20 gm. 
oatmeal were permitted on Mar. 1, increased to 52.5 gm. on Mar. 2. By this 
time glycosuria and coma symptoms were entirely cleared up, and alkali was di- 
minished. On Mar. 3 the diet consisted of soy beans and green vegetables. On 
Mar. 4 the diet was greatly reduced, consisting only of 90 gm. banana, 20 gm. oat- 
meal, 10 gm. potato, and 10 gm. cream. The patient was extremely weak, there- 
fore the attempt was made to build her up by a routine diabetic diet, in the hope 
that she might be strengthened for later undernutrition treatment. No gain of 
weight or strength was achieved, but glycosuria returned and the persisting acido- 
sis was greatly increased, as shown in the graphic record. It was again reduced 
by undernutrition, and brought to a minimum by a fast-day on Mar. 23. A 
carbohydrate period was then instituted to clear up the tendency to acidosis if 
possible, and the opportunity was taken to compare the assimilation of oatmeal 



CASE RECORDS 179 

and pure starch. On Mar. 24, 40 gm. Kahlbaum's soluble starch were the only 
nourishment given, and 80 gm. on each of the succeeding days, in ten doses of 8 
gm. each. On Mar. 29 a change was made to oatmeal, reducing the quantity of 
carbohydrate slightly as an allowance for the oat protein. Nevertheless a gly- 
cosuria of 1.39 gm. appeared on Mar. 31, proving the absence of any superiority 
of assimilation of the oatmeal over the soluble starch. The resulting traces of 
glycosuria were cleared up by a fast -day on Apr. 1 . Acidosis now being entirely 
absent, another attempt was made to overcome the persistent weakness by as 
high a diet as possible without glycosuria. Though the attempt was made to 
balance protein, fat, and carbohydrate to this end, the graphic record shows that 
acidosis returned promptly, and glycosuria resulted on Apr. 12. This was cleared 
up by a fast-day on Apr. 14. The attempt was then made to build up strength by 
still higher diet and to diminish acidosis by increasing carbohydrate, even at the 
cost of glycosuria, with the idea that glycosuria could later be checked by brief 
fasting. Acidosis was not controlled, and weight and strength were not gained, 
and on Apr. 25 this attempt was abandoned. From this date to May 1, pure pro- 
teici-fat diet was attempted, but both glycosuria and acidosis were present. At 
this time a more rigid program of undernutrition was begun. It will be seen 
chat the calories during May averaged less than 1000 daily, a maximum of car- 
bohydrate was introduced, and frequent fast-days were employed. The weight 
diminished very slightly. The complaints of weakness were about the same. 
Most of this period from May 1 to the end of July was vegetarian, chiefly nuts 
and green vegetables, of which the patient was fond. On June 30 an enormous fat 
intake was permitted experimentally, as mentioned under acidosis. No special 
virtue of the vegetarian regime was perceptible. Glycosuria and acidosis were 
practically absent during the undernutrition of the month of May; both returned 
with the higher caloric diet of June and July. This period was terminated be- 
cause of the increasing weakness of the patient, due particularly to the low pro- 
tein. In the period July 10 to 14 a test was made with raw pancreas feeding as 
described in Chapter IV. 

Most of the month of Aug. was occupied with pure protein-fat diet of between 
1000 and 1100 calories, and about 30 gm. protein. The patient was relieved 
of the fast-days, of which she had been complaining bitterly. Glycosuria was 
mostly absent, but acidosis was persistent. In Sept. the calories were increased, 
partly by use of alcohol, and a few fast-days mitigated by vegetables or alcohol 
were employed. Weight and strength were not thereby improved, and both 
glycosuria and acidosis were troublesome. Oct. was a period of marked undernu- 
trition, the calories being mostly about 900 daily, carbohydrate-free, except for 
two tests in which respectively 60 and 58. 8 gm. carbohydrate resulted in glycosuria, 
when added to this caloric intake. In Nov. and Dec. the carbohydrate-free diet 
was pushed to the upper limit of tolerance, so that traces of glycosuria and keto- 
nuria kept recurring and were checked by occasional fast-days. The attempt 
thus to build up weight and strength failed as usual. The patient was dismissed 



180 CHAPTER m 

on Dec. 20 with instructions to continue diet as during Dec. and to take a fast- 
day once each week. 

Acidosis. — ^The excretion of acetone bodies in the first few days was evidently 
very high, but the analyses were lost. Notwithstanding the alkali dosage, the 
urine was strongly acid, and the ammonia nitrogen was 1.7 gm. on Feb. 25 and 
1.93 gm. on Feb. 26. Each day the patient took 2.4 gm. potassium citrate, small 
quantities of light magnesia, and calcium carbonate in quantities equal to the so- 
diurii bicarbonate. It was thus hoped to provide a balance of salts, and perhaps 
also to neutralize some acid with a non-irritating substance such as chalk. The 
sodium bicarbonate dosage was as follows: Feb. 25, 20 gm.; Feb. 26, 32 gm.; Feb. 
27, 72 gm.; Feb. 28, 48 gm.; Mar. 1 to 7, 40 gm. daily; Mar. 8 to 20, 20 gm. daily. 
All alkali was stopped at this time. No efiect upon the carbohydrate tolerance 
was evident. 

As mentioned, acidosis was brought under control by the initial undernutri- 
tion period. With the high diets (Mar. 10 to 15) it returned very markedly, the 
ammonia nitrogen rising slightly above 1 gm. notwithstanding the alkali dosage, 
and the ketonuria reaching 28.7 gm. (as j8-oxybutyric) on Mar. 15. With a single 
fast-day (Mar. 16) the ammonia nitrogen fell to 0.63 gm. and the acetone bodies 
to 9.57 gm. With reduced diet the acidosis diminished further, and, was entirely 
abolished by the carbohydrate period, Mar. 24 to 31, the ammonia and acetone 
figures falling to normal, and the ferric chloride reaction turning entirely negative. 
MildCT acidosis returned with the beginning of mixed diet after Apr. 2, and it was 
proved that carbohydrate, even to the point of causing glycosuria, could not keep 
acidosis absent. Especially in the period Apr. 19 to 24 the carbohydrate was 
gradually increased to 90 gm., with a total diet as high as 2800 calories (over 75 
calories per kg. on 37 kg. weight). The highest glycosuria resulting was 7.26 
gm. on Apr. 24. This program was adopted on the principle frequently stated 
in the literature, that 90 gm. carbohydrate intake is worth a glycosuria of 7 gm. 
The attempt was to build up weight and strength with the high diet, while keep- 
ing acidosis in check by a favorable carbohydrate balance. Acidosis, however, 
remained present as stated, and the peculiar weakness and malaise characteristic 
of severely diabetic patients with even moderate acidosis persisted likewise. 
Carbohydrate had to be discontinued in order to check the steady increase of gly- 
cosuria. Thus the diets of Apr. 29 to 30 consisted of 61 gm. protein and 200 gm. 
fat. Both protein and fat were then diminished, until on May 1 the diet was 53 
gm. protein and 177 gm. fat. This would correspond to an orthodox diabetic diet 
of about 1.5 gm. protein and 37 calories per kg. Nevertheless slight glycosuria 
and heavy ferric chloride reactions persisted, and the ammonia nitrogen by May 
1 was up to 1.2 gm. May 2 was a fast-day with 34 gm. butter, this quantity of 
fat being abnost negligible for either good or ill. The glycosuria ceased before the 
close of the 24 hours, the ferric chloride reaction diminished to a trace, and the 
ammonia nitrogen fell to 0.6 gm. Thus 1 day of undernutrition accomplished 
' what had been impossible on full diets either rich or poor in carbohydrate. 



CASE RECORDS 



181 



For the next 3 months a vegetarian r6gime was tried, as described under "weight 
and nutrition" below. Because of the low protein and fat, a relatively high car- 
bohydrate tolerance was exhibited, which was also assisted by the very frequent 
fast-days. In this way both glycosuria and acidosis were almost continuously 
absent for a month. The hope of a gain in tolerance was disappointed, however, 
as demonstrated by the prompt return of both glycosuria and ketonuria when a 
moderate increase of diet was attempted in June and July. 

On June 30 an enormous fat intake was allowed experimentally for a single 
day, followed by a series of lower diets, as shown in Table II. 

TABLE n. 





Diet. 


Urine. 


Date. 


Protein. 


Fat. 


Carbo- 
hydrate. 


Calories. 


Volume. 


Sugar. 


Total 
nitrogen. 


NH.-N 


Acetone 

bodies (as 

l8-oxy- 

butyric). 


IHM 


gm- 


gm. 


im. 




cc. 


gm. 


gm. 


gm. 


gm. 


June 27 


43.1 


104.7 


87.0 


1403 


2320 


+ 


4.02 


0.35 


0.78 


" 28 


40.0 


104.8 


85.9 


1415 


3188 


3.31 


4.38 


0.41 


1.66 


" 29 


0.5 


123.9 


3.4 


1270* 


1858 





2.17 


0.35 


0.62 


" 30 


83.6 


448.6 


72.4 


4456 


2128 


+ 


4.55 


0.92 


4.67 


July 1 


74.7 


292.8 


51.0 


2707 


2629 


4.12 


11.38 


1.34 


8.57 


" 2 


57.4 


185.7 


64.0 


2013 


1422 


7.11 


4.54 


0.91 


3.21 


« 3 


57.6 


202.0 


68.3 


2107 


1852 


14.63 


6.22 


2.00 


5.64 


" 4 


41.0 


112.0 


39.0 


1295 


1411 


4.06 


6.28 


1.50 


. 2.73 


" S 


0.2 


0.2 


1.8 


290t 


1506 





4.14 


0.80 


0.47 


" 6 


36.3 


109.8 


72.6 


1315 


1528 





6.17 


0.38 


1.11 


" 7 


55.1 


101.2 


68.2 


1420 


1630 





7.02 


0.43 


0.48 



* Butter 150 gm., strawberties 50 gm., alcohol 25 gm. 
t Alcohol 40 gm. 



The relation between combustion of food fat and body fat is here illustrated. 
The huge ration of June 30 did not produce any explosive increase of acidosis. The 
acetone bodies showed a rise on the same day, but a more marked one the follow- 
ing day, while the ammonia nitrogen did not reach its summit until July 3. It is 
evident that what happened was not the conversion of any large proportion of the 
fat on June 30 into acetone bodies, but rather an injury of fat assimilation pro- 
duced by this excess and continued by reason of the fat rations (lower but still 
excessive) of July 1 to 3. On the fast-day of July 5, storage or depot fat was 
necessarily burned, yet the ammonia nitrogen was approximately the same as On 
June 30. On July 6, with a limited fat intake, the effect of carbohydrate was 
evident in producing a lower ammonia nitrogen excretion than on the fast-day. 
The entire observation is against the idea of a difference between food fat and 



182 CHAPTER in 

body fat in combustion, and indicates rather an overtaxing of fat metabolism by 
excessive intake and improvement of assimilation by relief from the strain. 

On the carbohydrate-free diet beginning in Aug., strong ferric chloride reactions 
and unduly high ammonia excretion were the rule. Temporary control of both 
glycosuria and acidosis was achieved with the low diets (about 900 calories) in early 
Oct. Thereafter it will be noted that the ferric chloride reactions were some- 
times negative and never more than slight, even on carbohydrate-free diet, the gen- 
eral diabetic condition being now under better control. The continuance of slight 
acidosis, however, throughout so much of the period of treatment represents one 
of the serious mistakes in the management of this case. 

Weight and Nutrition. — ^Weight at admission 40.1 kg., at discharge 35.2 kg.; 
i.e., a loss of 4.9 kg. The initial gain in weight, up to 43.5 kg. on Feb. 28, repre- 
sented a marked bicarbonate edema, simultaneous with the turning alkahne of 
the urine. Slighter edema was present on certain occasions later, notably Aug. 
15 and Nov. 7, being due apparently to sodium chloride and removed by diminish- 
ing the salt intake. 

On Mar. 21 the large fluid intake began to be restricted. The patient had 
been accustomed to large quantities of water for some months past and com- 
plained of thirst when the allowance was diminished by order; within a few days 
this complaint disappeared and the thirst remained normal thereafter. 

Vegetarian diet was tried for a period of nearly 3 months, chiefly because of 
the claims in some quarters concerning differences in the glycosuric effect of 
different proteins, and the bare possibility that meat protein might at least 
stimulate a greater flow of gastric juice and correspondingly of pancreatic juice, 
and thus perhaps depress the internal function of the pancreas by stimulating 
its external function. Undernutrition was employed at the same time to create 
the most favorable conditions, and acidosis was kept absent by such quantities 
of carbohydrate as seemed within the tolerance. Butter was regularly allowed, 
eggs rather frequently, and a Uttle bacon and bacon fat sometimes, but for much 
of the time the ration was vegetarian in the strictest sense, composed entirely of 
vegetables, fruits, nuts, soy beans, and occasional gluten preparations. There 
was no gain of tolerance, and no advantages of a vegetarian diet or evidence of 
specific differences between proteins were observed. 

Neither food nor feces was analyzed. The former was calculated as usual 
from the Atwater-Benedict tables. On this basis the following reckoning can be 
made for the period from Mar. 16 to Nov. 30, for which the records of both food 
and urine are complete. Also, the total period of 260 days is divisible into two 
nearly equal portions, namely, 136 days up to July 31, during which the diet was 
largely and sometimes wholly vegetarian and contained considerable carbo- 
hydrate, and 124 days after July 31, in which the protein was of animal origin 
and the diet was almost continuously carbohydrate-free. The results for the 
various periods may be compared as shown in Table III. 



CASE RECORDS 



183 







^ 










ej . 


g (^ 10 irj 




3 !3 


S CN ■^ll 




o5 


fe^ T-J 0\ ro 










.■§ o 










a g 


gm. 
2.63 
0.21 
2.40 






H 


T-4 ^ 

1 (M S .rt 




_g 


i^ 0\ 00 




■3 fl 2 


0\ O; o\ 




■SS-S 


S 0;' CO d 




Hss 


5 10 ^H 




^ o\ t>» 




■3 


i-H 




Total 
nitrogen 

in diet 
per day 
per kg. 


0. c^ vo 

E d d d 




2* fl-.. t^ 


. ■* ^ lO 






g CN >0 

"^ t^ 00 \o 




A .S 






nitr 
n in 
prote 
5.25). 


CN ■* 
S IN 0\' « 




" S^.i. 


Si cio in CN 




00 o_ 00 




aj ' 






H ■■V 


w ^ 


M 


Average 
protein 
per day 
per kg. 


sm. 
1.23 
1.44 
1.02 


a 


!•§&■ 


. <N rf OS 




tH^TJ 


E "3 ro t^' 


f^ 


I^R 


h3 


Th 10 re 









g 


2 


•<l; f) 


H 


3'a*.- 


.000 




o'S.S 


S « tN rC 




H^-o 


^ *^ ^., ^ 




g 


^" vo" i^ 




a 


-' 




Average 
calories 
per kg. 

per day. 


ce ro re 




CO PO re 










t|l 


ro ■* T-i 




^ !N 






C>l^ CN_ CN 




.5 


<N SO vo 




si^" 


*^ to w 

Ce_ (N VH 




,|, 


•W as 0" ■ 




^ -"^ so 
CO « ^ 






en 












>, 










tS 

-a 


^ 1 






"5 "C 






so OJ 






IN -a a 






^ ^=« 






• 2 n •— 4 






tal per 
nimal' 
egetab 






£<> 






H 


:: 


;; 


1 



184 CHAPTER ni 

The patient lost 5 kg. weight in 9 months. If it be assumed that 90 per cent 
of a weight change is ascribable to fat, in this instance the loss of nitrogenous 
"tissue" would not exceed 500 gm. Using Voit's figure of 3.4 per cent N, the 
possible loss of body nitrogen would then be 17 gm. If it be urged that in an 
emaciated person the wasting of "tissue" in proportion to fat is higher, the 
above comparison of intake and output shows that the patient must have been 
nearly in equilibrium. At worst, the nitrogen deficit must have been small, and 
it may be assumed that the diet fulfilled the purpose of protecting body protein 
from any extreme loss while maintaining prolonged undernutrition. 

Two deductions seem justified. (1) Digestion and absorption of protein 
were, as would be expected, distinctly better during the "animal" period, but the 
utilization of vegetable proteins, including the times when the diet was exclu- 
sively vegetable, was reasonably satisfactory. (2) Though the nitrogen intake 
was lower in the "vegetable" period, it must be called low also in the "animal" 
period, and it is evident that there is no serious obstacle to maintaining equilib- 
rium on strict carbohydrate-free diet with a low protein ration. It is to be borne 
in mind that the energy intake is a question not of food ingested but of food ab- 
sorbed. If it be permissible to assume that the same proportion of total calories 
as of nitrogen was lost in the feces, viz. 11.29 per cent, subtraction of this num- 
ber from the 33 calories ingested daily would leave an average of between 29 and 
30 calories absorbed daily per kg. of body weight. Accordingly, it would appear 
that this patient lived for 260 days on an average of 0.173 gm. N and 30 calories 
per kg. Work and exposure to cold were both far less than in ordinary individuals. 
On the other hand, the rather tall, very emaciated figure presented a dispropor- 
tionate surface. Losses in sugar and acetone bodies were sKght. On the whole, 
the figures obtained correspond satisfactorily to the known laws of metabolism 
in normal persons. 

Subsequent History. — On Jan. 14, 1915, the patient reported by telephone that 
she was feeling well and had cleared up occasional traces of glycosuria by fast- 
days. On Jan. 20 she reported increasing difficulty in remaining sugar-free, and 
was instructed to return to the hospital if difficulty continued. Nothing more 
was heard until Apr. 1, when a letter stated that she had returned to her home 
in Indiana. On Apr. 26 a response to a letter of inquiry showed that the cause of 
her silence and removal was her adoption of Christian Science. Occasional 
later reports showed that she was eating everything at will, including much 
candy,, and gradually losing strength. Death occurred from simple weakness 
the first of Oct. 1915, the terminal collapse being brought on by taking a dose of 
Epsom salts. 

Remarks. — The patient, when received, was undoubtedly close to coma. She 
appeared then as having diabetes of extreme severity. The results obtained 
seemed highly favorable. In the light of later experience this treatment was 
very bad. 

Part of the fault lay with the patient, who had always eaten injudiciously 



CASE RECORDS 185 

and was the most unruly of the entire series for dietary control. The high 
diets, the persistence of glycosuria and ketonuria through considerable periods, 
and the changes in program from time to time were in some measure forced by the 
necessity of appeasing the patient's demands and meeting her psychic needs. 
She insisted not only upon nourishment but also taste and satiety, and slight pri- 
vations brought on hysterical tears and melancholy which seemed serious as a 
possible influence upon the diabetes, though, as a matter of fact, no particular 
influence of psychic upsets upon the food tolerance was observed. She was given 
unusual leeway as being the first patient. 

The cause of the final disaster was also instructive. It is noteworthy that al- 
though a very careful limitation of diet both quantitatively and qualitatively 
had resulted in threatened coma at the time of admission, subsequently on abso- 
lutely unrestricted diet no symptoms of acidosis were described, evidently be- 
cause the patient lived so largely on carbohydrate, and the polyiiria aided in the 
elimination of acetone bodies. Although the patient was young and the kind 
that typically dies in coma, death occurred from simple wasting and asthenia. 

The chief difficulty consisted in inexperience with the treatment. The cautious 
manner of beginning treatment, and the partial, irregular, and inadequate charac- 
ter of the measures employed belonged to this stage of uncertainty and orienta- 
tion. It showed the viciousness of some of the accepted methods in the man- 
agement of diabetes. The same patient admitted at a later time could have been 
treated far better; and the case, though severe, was mild in comparison with 
some of the later ones. A bold initial fast, followed by testing of the tolerance 
for different classes of food and arrangement of a diet accordingly, would have 
brought far quicker and better results. 

The actual accomplishment was that the patient was kept alive in the hospital 
from Feb. 24 to Dec. 20, with a loss of 5 kg. (one-eighth of her weight at en- 
trance), and about a corresponding diminution of strength. Glycosuria and 
acidosis were kept entirely absent at certain times, and were controlled within 
small quantities at all times. Actual food tolerance was slightly less at the end 
than in the earlier part of treatment, and the progress was slowly but distinctly 
downward. The bungling and inadequate treatment furnished abundant reason 
for this slight downward progress in 10 months, and no "spontaneous" cause 
need be assumed. Methods and results of this sort have been common with a 
large proportion of practitioners who have undertaken to apply the fasting 
therapy. The record of this patient stands as a useful example of how a case 
should not be treated. 

CASE NO. 2. 

Female, unmarried, age 17 yrs. Italian, sewing machine operator. Ad- 
mitted Apr. 13, 1914. 

Family History. — Grandparents healthy as far as known. Father a day laborer 
and short of stature; weight about 200 pounds. Mother short, normal figure, 



CASE RECORDS 187 

was agreeable to this Italian patient. In other words, the fast was not broken 
(as usual) by carbohydrate alone, but fat was introduced to make a total of 2000 
calories. Also on the following days, diets low and relatively high in fat were 
comparfed, and on Apr. 30 a day of 100 gm. olive oil was given instead of a regu- 
lar fast-day, according to the practice of some authorities. The results are dis- 
cussed elsewhere (Chapter VI). They illustrate the harmfulness of attempts to 
use fat in this manner. In the first few days of May a rather low diet was given, 
with absence of glycosuria. The succeeding period represents a low calory diet, 
with as much carbohydrate as possible and frequently repeated fast-days for the 
purpose of overcoming the persistent ferric chloride reaction. On June 11 an 
enormous fat diet was given (137 gm. protein, 34 gm. carbohydrate, 6672 calories 
= 167 calories per kg.) . A slight rise in the ammonia followed, but the patient's 
appetite was spoiled so she could take only a low diet for several days. On June 
17 a less extreme fat diet was begun, which nevertheless represented not far from 
100 calories per kg. of body weight. The results are discussed in Chapter VI. 
The onset of glycosuria and the marked rise of acidosis are the striking features. 
July S was a fast-day with alcohol. Thereafter a low diet was given, relatively 
rich in carbohydrate. Under this program both glycosuria and acidosis cleared 
up and were kept absent. 

The patient was discharged Aug. 14, symptom-free and feeling well and strong. 
The hospital stay was uneventful except for occasional headaches for which no 
cause was found. 

Acidosis. — Although there were no signs of coma, the analyses in the first few 
days indicated that trouble would have resulted before long on the restricted 
diet. On Apr. 14 to IS no alkali was given, and the urine contained 2.4 to 2.7 
gm. ammonia nitrogen and 4.2 to 7.0 gm. acetone bodies (as |S-oxybutyric) . 
Apr. 16 to 20, 20 gm. sodium bicarbonate were given daily, and 10 gm. on Apr. 21, 
after which alkali was stopped. The rise of ketonuria, up to 12.1 gm. /3-oxybutyric 
acid on Apr. 18, was to be expected, but at the same time the ammonia, instead of 
falling, remained little changed, and actually rose to 3.1 gm. ammonia nitrogen 
on Apr. 18. With diminished fat and increased carbohydrate intake on Apr. 19 
there was a drop in both ammonia and total nitrogen, but the steepest fall of the 
ammonia occurred on fasting. Thereafter the three principal peaks of the 
ammonia curve (Apr. 23, May 2, and June 19 to July 3) are clearly associated 
with the fat content of the diet. It is evident from the graphic chart that acidosis 
was not checked by hberal quantities of carbohydrate and protein, nor by a fav- 
orable carbohydrate balance, but on the contrary rose and fell according to the 
ingestion of fat. For about the last month in the hospital acidosis was entirely 
absent on a diet moderate in protein, relatively abundant in carbohydrate, and 
low in fat. 

Weight and Nutrition. — Weight at admission 42.6 kg., at discharge 40 kg.; 
i,e., a loss of 2.6 kg. The variations and excesses in diet were experimental. 
The diet at discharge was approximately 56 gm. protein, 120 gm. carbohydrate. 



188 CHAPTER in 

and 1400 calories (1.4 gm. protein and 35 calories per kg., reduced slightly by 
occasional fast-days). The patient's figure and strength at discharge appeared 
normal. The diet was planned as one on which she could work. She was in- 
structed not to gain weight, and it was proposed to give her instructions there- 
after chiefly on the basis of her body weight. 

Remarks. — ^Aside from the intentional experimental variations, the treatment 
was fairly efficient and the result good. The reduction in weight and the arrange- 
ment of the final diet, restricted in total calories, adequate "in protein and rather 
liberal in carbohydrate, was about what was needed for a relatively mild case, 
such as this one by this time had proved itself to be. By comparison of the 
diets of Apr. 14, IS, 18, and 19 with those of Aug. 9 and 11, it will be seen that 
the calories are about the same, while the carbohydrate, counting also that deriva- 
ble from proteia, is higher in the latter period. Along with this, the sharp 
contrast as respects glycosuria and ketonuria shows a decided upward progress 
in this 17 year old girl during these 4 months. 

Subseqtient History. — ^After discharge on Aug. 14, the patient followed diet and 
remained sugar-free for about a month at home. Owing to poverty it was almost 
impossible for her to obtain the necessary food, and she gradually began to take 
the diet of the rest of the family. Sugar reappeared, followed by other symptoms. 
She was readmitted Nov. 30, 1914, complaining of polydipsia, polsoiria, and for the 
last few days loss of appetite and drowsiness. 

Second Admission. — A 4 day fast was instituted, glycosuria ceasing on the 3rd 
day. On Dec. 4, green vegetables containing 20.5 gm. carbohydrate were taken 
without glycosuria. Another fast-day was then given as a therapeutic measure, 
and a mixed diet of eggs, butter, steak, and vegetables gradually begun. Slight 
glycosuria appeared within a few days. Beginning Dec. 16, the diet was almost 
constantly carbohydrate-free and unduly high in calories. Ketonuria was pres- 
ent most of the time up to July 24. Then, after a fast-day, a carbohydrate test 
was given in the form of green vegetables as usual. Beginning with 10 gm. car- 
bohydrate on July 26, an increase of 10 gm. daily was made. Aug. 4, on 100 gm. 
carbohydrate, she showed a trace of sugar, which disappeared the next day when 
the same carbohydrate was given. The true hmit was reached on Aug. 8 with 
130 gm. carbohydrate. Accordingly, 120 gm., which had been tolerated the pre- 
vious day, were accepted as her tolerance. The acidosis was thus cleared up 
(compare with increase of acidosis when fat was given in Apr., 1914). It returned 
in smaU amount on the subsequent carbohydrate-free diet, then diminished, so 
that after Sept. 7 it was absent. Another carbohydrate tolerance test was madfe 
beginning Oct. 11, and the limit was found to be practically the same as in Aug. 
Small quantities of carbohydrate were added to the diet in Nov., but discon- 
tinued on account of glycosuria. Beginning Dec. 13, a third carbohydrate tol- 
erance test showed imchanged assunilation, and cleared up the sUght ketonuria 
which had again developed on protein-fat diet. Carbohydrate was again included 
in a diet somewhat lower in calories, but was discontinued on account of persistent 



CASE RECORDS 189 

slight glycosuria. Strenuous exercise was a feature of the treatment during this 
period in the hospital. The observations are discussed in Chapter V. The 
patient was discharged Feb. 2, appearing healthy and well nourished and feeling 
strong and capable of hard work. 

Acidosis. — The ammonia excretion was constantly higher than that of normal 
persons; perhaps not higher than some normal persons would show on the same 
diet. No determinations were made during the carbohydrate tests, when lower 
values might have been found. A fall of the ammom"a on fast-days and a rise on 
carbohydrate-free diet is shown by portions of the curve in Apr., May, and June; 
this is doubtless due in part to corresponding variations in total nitrogen excre- 
tion, but also illustrates the difference between fasting and protein-fat diet. 
Beginning Dec. S, it is evident that a fast-day, followed by a reduction of fat in 
the diet while keeping protein the same, resulted in a drop in ammonia excre- 
tion. The carbon dioxide-combining power of the plasma remained in the 
neighborhood of normal without alkali dosage, but nevertheless showed a ten- 
dency to sink somewhat below the low normal limit. This was one of the patients 
who showed a fall in blood bicarbonate on fasting, as seen particularly after the 
fast-days of May 1 and Sept. 12. Certain other fluctuations in this curve are dis- 
cussed in Chapter V in connection with exercise. 

Blood Sugar. — This was mostly about 0.2 per cent. A rise is seen at the close 
of the carbohydrate tolerance test in Oct. Analyses were not made during the 
other carbohydrate tests. The normal values from Apr. 30 to May 11, and on 
Sept. 22 and 23, showed that a reduction was possible by suitable low calory diet, 
and the failure to insist upon such a level was one of the faults of the treatment. 

Weight and Nutrition. — In general the lowest diets are those of Aug. and Oct. 
and the dismissal diet about the 1st of Feb. These amounted to 1300 to 1500 
calories, which for a body weight of 40 kg. would equal 35 calories or more per 
kg. At other times this diet was increased by fat to as much as 3500 calories, 
or some 60 calories per kg. Two modifying features come into account. One 
is the number of fast-days, which serve to diminish the average intake some- 
what below this figure. Second, the patient was kept most of the time on very 
heavy exercise, so that the caloric requirement was increased. The patient en- 
tered weighing 45.6 kg.; namely, a gain of some 5 kg. since her former discharge, 
with a corresponding loss of tolerance. She was dismissed weighing 39 kg.; 
i.e., with a loss of 6.6 kg. in 14 months in the hospital. To this extent the treat- 
ment was one of undernutrition. 

Remarks. — It was above noted that during 4 months in hospital, at the first 
admission, progress was upward. The patient was at home about 3i months and 
broke diet in the latter portion of this period. The downward progress is plainly 
evident. After her second admission she frequently showed sugar on carbohy- 
drate-free diet. Also her limit of tolerance for carbohydrate alone, in the green 
vegetable tests of Aug., Oct., and Dec, 1915, was almost exactly the quantity 
which could be included in her regular mixed diet in Aug., 1914, without any 



190 CHAPTER III 

appearance of glycosuria. It is thus clearly confirmed that a marked and last- 
ing injury of assimilation can be produced by a few months of unregulated diet. 
On the other hand, the former carbohydrate tolerance tests of Aug., Oct., and 
Dec, 1915, covered a period of S months, and conclusively proved the absence of 
any perceptible downward progress during that time. Also the weight remained 
essentially the same, so that no disturbing factor was thus introduced. Moreover, 
comparison of the tolerance at the beginning and end of the second hospital 
period shows that glycosuria appeared on Dec. 14, 1914, on a diet of 60 gm. pro- 
tein, 42 gm. carbohydrate, and 981 calories. If all these earlier occurrences of 
slight glycosuria be ignored, it is still evident that on repeated occasions in Jan., 
Feb., and thereafter, glycosuria was present on carbohydrate-free diets of some 
1700 calories. In contrast to this, it is seen that from Dec. 27, 1915, to Jan. 1, 
1916, a diet of 1760 calories with 10 to 30 gm. carbohydrate was tolerated without 
glycosuria, and the protein in this diet was fully as high as in the above men- 
tioned carbohydrate-free periods. Glycosuria appeared only on Jan. 6, toward 
the close of another week on the 30 gm. carbohydrate allowance. It was thus 
present on Jan. 11, but cleared up on withdrawing carbohydrate from the diet. 
A slight gain in food tolerance is thus evident during these 14 months in hospital, 
and this upward tendency is the more remarkable in view of the improper treat- 
ment, with its long periods of overfeeding and almost continuous marked hyper- 
glycemia. The essential criticism of the treatment in this period is that by 
pernicious protein-fat overfeeding (up to 60 calories per kg.) it held back the ten- 
dency to improvement, and ultimately sacrificed 6| kg. weight for only the slight 
gain of assimilation above mentioned. An excellent physical condition was main- 
tained throughout, and the patient was discharged seemingly in splendid health. 
The failure of the plan of feeding for immediate weight and strength is well dem- 
onstrated by this prolonged trial. The transitory well-being is too dearly bought 
at the price indicated by the laboratory findings. Proper management would 
have imposed a rigid low diet from the outset and insisted upon continuously 
normal urine and blood. A sharper initial fall of weight would have resulted. 
A small quantity of carbohydrate could have been included in such a low calory 
diet. Under such a program there is little doubt that the patient could have been 
discharged in fully as good physical condition and on fully as high a total diet as 
was actually the case; and the diet could have been balanced properly with car- 
bohydrate, and the entire condition from the standpoint of the diabetes would 
have been far more favorable. 

Subsequent History. — After discharge on Feb. 2, 1916, diet was followed until 
Mar. 8, when the patient began to take two slices of bread daily in addition to the 
weighed diet, because of a strong craving for carbohydrate. Sugar had been ab- 
sent before, but then reappeared and continued. She was doing 5 hours work 
on the sewing machine at home and 2 hours housework daily, and in addition 
walked two miles two or three times a week. A fast-day was taken once a week 
up to the 1st of Mar. 



CASE RECORDS 191 

Third Admission. — Mar. 20, 1916. Weight 39.4 kg. Nutrition and strength 
still appeared very good. Fasting was imposed Mar. 21 to 23 inclusive, then low 
protein-fat diet, gradually increasing from 1000 to 1200 up to 1800 calories, with 
protein ranging from 40 or 50 up to 60 or 70 gm. daily. The patient was again 
discharged on July 12 at her own request, still appearing in excellent condition. 
Headaches had been somewhat relieved after prescription of glasses by an 
oculist. 

Acidosis. — It is of interest that heavy acidosis was brought on by the addition 
of two slices of bread to the weighed diet on which both glycosuria and acidosis 
had been absent. Fasting was begun on the day following admission (Mar. 21). 
The patient was depressed, dizzy, and significantly unwell. The finding of 33.4 
per cent plasma bicarbonate showed the reason. Sodium bicarbonate was then 
given in 3 doses of 10 gm. each. Within half an hour after the first dose the clini 
cal effect was striking. The headache, dizziness, depression, and malaise van- 
ished, and were replaced by comfort and cheerfulness. It is possible that fasting 
alone would have been badly borne, as the tendency to a fall in blood alkalinity 
on fasting was previously noted in this patient. No more alkali was given. The 
CO2 capacity was found normal on the day after the bicarbonate dosage, but fell 
to 46 per cent on the succeeding day (Mar. 23). On this day also glycosuria 
ceased. Mar. 24 to 27, a trial was made of carbohydrate-free diet, which fre- 
quently relieves fasting acidosis. On Mar. 24 nothing but 21 gm. protein was 
fed, the diet being coffee, soup, and veal. The blood bicarbonate rose a trifle. 
On Mar. 25 the diet contained 40 gm. protein and 800 calories. Thereafter pro- 
tein was increased and fat diminished, so that on Mar. 27 the diet was 70 gm. 
protein and 600 calories. The net result of these low protein-fat rations was 
that by the morning of Mar. 26 the blood bicarbonate had risen to 52.8 per cent. 
On Mar. 28, the diet was sharply reduced to 16 gm. protein and 10 gm. carbohy- 
drate. The blood alkalinity fell sharply as on a fast-day; i.e., to 40 per cent on the 
morning of Mar. 29. Beginning Mar. 29, the diet was limited to green vegetables. 
On this, by the morning of Mar. 31, the CO2 capacity had risen to 44 per cent, 
though the carbohydrate intake had amounted to only 30 gm. on Mar. 30. By 
Apr. 7, the plasma alkalinity had risen to within normal limits on low protein-fat 
diet. Thereafter it remained generally at a low normal level. No reason is 
known for the low reading of 45.6 per cent on June 27, unless it were the in- 
creased fat intake. By July 7, it had returned to normal without the aid of 
alkali, possibly with the aid of the small allowance of carbohydrate. The other 
tests were not parallel with the plasma bicarbonate. The ammonia nitrogen 
at first fell from 3.4 gm. on Mar. 20 to 1.94 gm. on Mar. 22, then remained nearly 
stationary to Mar. 27, thus corresponding to the plasma bicarbonate. But 
when the plasma bicarbonate fell at the beginning of the vegetable period, the 
ammonia fell also. Later, on protein-fat diet, the ammonia was a more sensitive 
indicator of acidosis than the plasma bicarbonate, being unduly high (Apr. 14, 
June 6 to 8) at times when the plasma bicarbonate was approximately normal. 



192 CHAPTER m 

The ferric chloride reaction became negative early in the vegetable period, at 
the very time when the plasma bicarbonate fell. It remained negative thereafter. 

Blood Sugar. — ^The fall during the initial period of fasting and undernutrition 
is evident from the graphic record. Subsequently it rose, and remained much 
of the time in the neighborhood of 0.2 per cent. The decline to a nearly nor- 
mal value shortly before discharge is in conformity with the other improvement. 

Weight and Nutrition.— Weight at admission 39.3 kg.; i.e., the same as at the 
previous discharge. Weight at discharge 35.2 kg. Nearly 4 months of treat- 
ment thus represented undernutrition to the extent of 4.1 kg. This under- 
nutrition was imposed especially at the beginning of this hospital period. -From 
Apr. 18 to discharge there was an actual gain of 1 kg. During most of the time 
one egg was allowed on fast-days, but beginning with July the fast-days were 
made absolute. The daily allowance of 70 gm. protein, 10 to 15 gm. carbohydrate, 
and 1800 calories was thus reduced to an average of 60 gm. protein and 1540 
calories (1.7 gm. protein and 44 calories per kg.). 

Remarks. — The carbohydrate tolerance test Mar. 28 to Apr. 4 showed an assimi- 
lation not above 60 gm. carbohydrate. Glycosuria also appeared subsequently on 
protein-fat diets lower than those previously tolerated. Very decided downward 
progress was thus clearly demonstrated in consequence of violations of diet, 
during less than 2 months at home, the violations being said to have been limited 
to less than 1 month. Susceptibihty of this case to rapid downward progress 
on dietary overstrain is thus proved. On the other hand, in nearly 4 months 
of hospital sojourn this time, the progress was demonstrably upward. From 
Apr. 18 onward, as mentioned, there was a gain of 1 kg. weight, and at the same 
time the patient became able to remain free from glycosuria and ketonuria on 
diets decidedly higher in protein, fat, and carbohydrate than those on which 
glycosuria repeatedly occurred earUer in the period. The tendency of the blood 
sugar likewise was downward. Furthermore this improvement occurred in spite 
of grossly excessive diets, the tendency to spontaneous upward progress being 
thus all the more remarkable. In extenuation of the diet only two excuses can 
be offered. One is that the patient was taking heavy exercise, and it had not 
yet been learned that this does not atone for excessive diet. The other is that 
it was known that the patient at home would not adhere to any diet which kept 
her at all hungry or uncomfortable. Accordingly she was allowed this diet, on 
which her progress seemed at least temporarily favorable, in preference to a 
more beneficial diet which would be more Uable to be violated. 

Fourth Admission. — Sept. 11, 1916. (No graphic chart.) Patient returned to 
hospital with the usual history of having broken diet. Heavy sugar and ferric 
chloride reactions were now present on her former diet. A 4 day fast was neces- 
sary. A carbohydrate test with green vegetables in the usual manner showed a 
tolerance of 50 gm. A carbohydrate-free diet was then begun, with 40 gm. pro- 
tein and 600 calories. The experiment was then performed of keeping this pro- 
tern the same while gradually increasing fat to make a totalof 1300 calories (see 



CASE ItECOEDS 193 

Chapter VI). The result was glycosuria, while the ferric chloride reaction re- 
mained negative. Thereafter with less fat (900 to 1200 total calories) and the 
same protein, glycosuria was absent, but returned when the protein was in- 
creased to SO to 65 gm. She was discharged on Dec. 4, 1916, stiU in fair subjective 
health. 

Acidosis. — The COj capacity of the plasma at first was 35.5 per cent. Weak- 
ness and malaise, making her imfit for work, were the only clinical symptoms of 
acidosis. With 4 days of fasting, the CO2 capacity rose to 53.3 per cent. After 2 
days respectively of 10 and 20 gm. carbohydrate, it was 59.5 per cent, and at the 
close of the carbohydrate test (Sept. 22) 58 per cent. This reaction to fasting is 
noteworthy ia a patient who on previous admissions had shown such decided 
falls in blood bicarbonate on fasting. Likewise the heavy ferric chloride reaction 
diminished on fasting and cleared up during the vegetable period. The am- 
monia nitrogen, which was 3.3 gm. on the prescribed diet, dropped to 2 gm. 
at the close of fasting, and to 0.43 gm. on the fast-day (Sept. 23) following the 
vegetable period. Thereafter on protein-fat diets the plasma bicarbonate re- 
mained at a high normal level (59.8 to 68.8 per cent) and the ferric chloride reac- 
tion continued negative. The ammonia nitrogen ranged from 0.8 to 1.5 gm., 
and was thus the most delicate index of acidosis. 

Blood Sugar. — This was 0.218 per cent in whole blood and 0.238 per cent in 
plasma on the first day of fasting (Sept. 13), 0.192 per cent in plasma on the last 
day of fasting (Sept. 16). It was never brought lower than 0.122 per cent in 
whole blood and 0.147 per cent in plasma. The last analysis, with sugar-free 
urine, showed 0.202 per cent plasma sugar. 

Weight and Nutrition. — ^Weight at admission 41 kg., part of which was edema. 
Weight at discharge 34.3 kg. The final weight was thus only about 1 kg. less 
than at the previous discharge, but otherwise the condition was much worse. 
The carbohydrate test above mentioned indicated a loss of only 10 gm. tolerance. 
A truer index is afforded by the fact that traces of glycosuria now tended to ap- 
pear on relatively low carbohydrate-free diet. In contrast to the 70 gm. protein, 
10 to 15 gm. carbohydrate, and 1800 calories tolerated at the former discharge, 
the diet at discharge this time had to be limited to 45 gm. protein and 1200 calories 
(1.3 gm. protein and 35 calories per kg., reduced by the weekly fast-days to 1.1 
gm. protein and 30 calories average). Moreover, marked hyperglycemia was con- 
tinuous on this diet as stated, and glycosuria appeared upon very slight increase 
of either protein or fat. The patient had again demonstrated how rapidly she 
could progress downward with improper diet in the short period of 2 months at 
home. At this discharge she was distinctly weaker than ever before, though still 
comfortable and able to do housework. The treatment had not been radical, but 
she had been fed during the whole of this hospital period to the limit of her 
tolerance in order to keep up her weight and strength. 

Subsequent History. — A note received from the family Mar. 14, 1917, stated that 
the patient died at 2:30 a.m. that day. She had again broken diet because of the 



194 CHAPTER III 

unfavorable environment, and the diabetes took its natural rapid course. She 
refused the petitions of her family that she return to the hospital. 

Remarks. — ^The patient had been kept alive and almost uninterruptedly com- 
fortable for 3 years under treatment. In view of her state of intelligence, will 
power, and environment, this was probably as much as could have been accom- 
plished unless she had been kept continuously in an institution. The chief 
scientific interest in the case lies in its demonstration of rapid downward progress 
with dietary indiscretions, and complete absence of downward progress and 
distinct tendency to upward progress even under treatment which never was 
radical enough to remove the continuous evidences of slight metabolic overstrain. 

CASE NO. 3. 

.Female, unmarried, age 26 yrs. American; no occupation. Admitted May 
23, 1914. 

Family History. — Father was never strong, and died when patient was 5 years 
old. Autopsy is said to have revealed numerous intestinal ulcers. His parents 
lived to healthy old age. Patient's mother is alive and well; her father died at age 
of 28 of tuberculosis said to have resulted from a career of dissipation; also her 
brother died of tuberculosis, and her sister with acute melancholia. Patient 
has one brother aged 32 who suffers from nervousness and indigestion. No 
diabetes or other family diseases known. 

; Past History. — ^Healthy life in excellent hygienic conditions, but numerous in- 
fections. Measles, mumps, chicken-pox in early childhood. Typhoid at 8. 
Tonsillitis at 16 with recurrent attacks in following years until right tonsil was re- ' 
moved 3 years ago. Only a little sore throat since then. S years ago " colitis" 
for 10 days; fever, vomiting, and dull aching pain in upper abdomen, consider- 
able bloody diarrhea, no jaundice. Several slight attacks of grippe, the last 
about 3 years ago. 4 years ago, "intercostal rheumatism;" in bed about a 
week, no herpes. Quiet life; no overstudy, but considerable social activities in 
recent years, and some exhaustion after attending several dances in the same week. 
Not nervous. Worry and loss of sleep for some time following unhappy love 
affair 4 years ago, but this has entirely passed off. Moderate appetite, but she 
has eaten even more candy than the average girl. 

Present Illness.— Jan. 12, 1914, after having been in apparently perfect health, 
patient woke up with malaise and slight abdominal pain. The attack subsided 
with fasting and bed- rest, but on account of slight tenderness and rigidity, 
laparotomy was performed on Jan. 14, revealing obliterative appendicitis and 
blood clots about right ovary, treated by removal of appendix and one ovary. 
Incision healed per primam, but IS days after operation phlebitis occurred, first in 
left leg, then in right. Left leg has required bandaging until recently. Urine was 
reported normal in hospital, but it is doubtful if tests for sugar were made. 
Weakness and weariness felt at this time were attributed to convalescence and 
the patient went to summer resorts to recuperate. Polyphagia, polydipsia and 



CASE RECORDS 



195 



polyuria began, and most of her luxuriant hair fell out. The normal weight of 
120 pounds diminished to 109 pounds. 2 weeks before admission, diabetes was 
diagnosed. The laboratory reports showed 8.3 per cent sugar and heavy ferric 
chloride reaction. A diet was prescribed containing considerable starch. Since 
then, rapid dimming of vision has been noticed. Menstruation has continued. 



TABLE IV. 





Diet. 


Urine. 


Date. 


Protein. 


Fat. 


Carbo- 
hydrate. 


Alcohol. 


Calories. 


Volume. 


Sugar. 


NHj-N 


Acetone 

3odies (as 

fl-oxy- 

butync). 


IDM 


gm. 


gm. 


gm. 


gm. 




cc. 


gm. 


gm. 


gm. 


May 24 


82.8 


127.5 


127.7 


7.5 


1854 


2010 


47.2 


1.39 


2.27 


" 25 


126.5 


175.0 


272 


4.0 


3259 


2470 


68.0 


1.06 


2.31 


" 26 


: 


Fast-day. 


35.0 


245 


910 


4.2 


0.88 


0.88 


" 27 




tc 




25.0 


175 


644 





1.00 


1.63 


" 28 


4.2 


0.8 


25 


— 


122 


825 





1.15 


1.93 


" 29 


10.9 


2.5 


60 


— 


302 


934 





1.23 


0.64 


" 30 


37.0 


9.5 


162 


— 


8*8 


1700 


7.99 


1.31 


2.08 


" 31 


11.6 


2.7 


52 


— 


421 


1362 


4.22 


0.34 


1.05 


June 1 


7.0 


1.2 


22 


— 


125 


1106 





0.38 


0.21 


" 2 


6.2 


1.4 


16 




99 


957 





0.46 


0.45 


" 3 


10.8 


3.7 


37 


— 


222 


866 


— 


0.54 


0.41 


" 4 


24.7 


10.1 


98 


— 


568 


1008 





0.53 


0.37 


" 5 




Fast-day. 


30.0 


210 


1758 





0.35 


0.74 


" 6 


14.0 


1.8 1 98 


— 


474 


774 


— 


0.55 


0.80 


" 7 




Fast-day. 


30.0 


210 


1325 





0.32 


0.35 


" 8 


14.0 


1.7 


85 


— 


419 


727 





0.67 


0.88 


" 9 


31.7 


6.4 


144 


— 


779 


2009 


4.31 


0.74 


0.69 


" 10 


40.1 


13.6 


147 


— 


893 


2278 


4.57 


0.43 


0.48 


" 11 


43.7 


15.1 


150 


— 


932 


2728 


4.19 


0.55 


0.5S 


" 12 


1.6 


— 


7.8 


25.0 


220 


2054 





0.35 


0.41 


" 13 


43.2 


10.4 


113 


— 


735 


1969 





0.41 


0.23 


" 14 


40.1 


11.7 


124 


— 


778 


2060 





0.27 


0.33 


" 15 


38.5 


7.8 


136 


— 


787 


1878 





0.26 


0.31 



Physical Examination. — Height 161.3 cm. Patient appears rather juvenile for 
her age; stiU well nourished, and with look of perfect health. Mouth and teeth 
in good condition. Right tonsil missing, left appears normal. No enlarged 
lymph nodes. Reflexes normal. Examination otherwise negative. 

Treatment. — (No graphic chart.) An observation diet was first permitted simi- 
lar to what the patient had been taking. The initial treatment is shown in 
Table IV. 



196 



CHAPTER in 



The most disturbing symptom was the blurred vision. The patient compared 
it to the efiEect of atropine. In the early days in hospital she became unable to 
read even with glasses. An oculist found no organic change, and vision rap- 
idly cleared in parallel with the urine. After an uneventful period of hospital 
observation without return of any symptoms, the patient was discharged on 
July 24. 

Acidosis. — This was never heavy, and was easily controlled by reason of the 
high carbohydrate tolerance. The only alkali used was 20 and IS gm. sodium 
bicarbonate respectively on the &st 2 days in hospital. 

Weight and Nutrition. — Weight at admission 46.5 kg., at discharge 43.4 kg. 
The apparent reduction of weight was thus 3.1 kg., but actually must have been 
somewhat more, as the dried tissues recovered their normal water content during 
undernutrition after cessation of glycosuria. The treatment was characterized 
by low protein, low calory diets, as liberal as possible in carbohydrate. At 
first such diets were exclusively vegetable. Glycosuria at first resulted from 
140 gm. carbohydrate, but by June 16, 171 gm. carbohydrate were taken without 
glycosuria. One egg was then added to the diet; and after June 22, 200 to 225 
gm. carbohydrate could be taken daily without glycosuria. As a precaution, 
however, the allowance was diminished to 150 gm. The diet prescribed at dis- 
charge represented approximately 70 to 80 gm. protein (largely vegetable), 150 
gm. carbohydrate, and 1200 to 1500 calories (1.5 to 1.75 gm. protein and 26 to 33 
calories per kg., without fast-days). As the patient was about 9 kg. below nor- 
mal weight, this allowance was considered prudent; and she was permitted to 
estimate her diet instead of weighing it, on condition that she be guided by her 
body weight and not allow herself to gain much flesh. She was stiU sufiiciently 
well nourished to look and feel entirely healthy. The degree of undernutrition 
in hospital, and the extent to which fat was excluded and carbohydrate empha- 
sized in the diet, can be shown by the following table. 





Total. 


Average per day. 


Calories in diet for 61 days 


61,287 
2,788.7 gm. 
2,073.1 " 
7,121.0 " 


1005 


Protein " " "61 " 


45.7 gm. 
34 " 


Fat " " " 61 " 


Carbohydrate " " "61 " 


117 " 






Nitrogen in diet for 61 days (Protein -f- 6.25) 


446.0 gm. 
278.6 " 
266.5 " 


7 ^ CTTYl 


" " " " 49 " ( " ■^6.25) 


5.68 " 
5 44 " 


" in urine "49 " 


" " " per kg. per day (average 44 kg.) 


0.125" 



It should be borne in mind that the diet was strictly vegetarian, chiefly green 
vegetables, except for a single egg daily after June 16. A considerable propor- 
tion of the protein was therefore non-absorbable, so that the close correspondence 



CASE RECORDS 197 

between food and urine nitrogen must be attributed not to unusually good utili- 
zation of food, but rather to loss of body nitrogen. Protein restriction to this 
degree was doubtless unnecessary, but the rigid undernutrition was a commendable 
feature. 

Subsequent History. — The patient led a thoroughly normal and comfortable life, 
but managed her diet so as to permit a gradual gain in weight. Occasional traces 
of glycosuria returned, and these and the gain in weight were not checked by mod- 
erate exercise which was advised. Presumably eating was increased in propor- 
tion to the exercise. During the 2 years outside the hospital the patient had 
been married and divorced, and though the glycosuria was attributed partly to 
worry, it probably was essentially of dietetic origin. The predominant difficulty 
consisted in traveling and hotel life, where vegetables were often cooked with 
starch and even sugar. Though feeling perfectly well, she reentered the hospital 
for observation on request. 

Second Admission. — ^Jime 6, 1916. Weight 49.2 kg. The urine showed a 
trace of sugar which cleared up readily without fasting. The carbohydrate 
tolerance was not accurately tested, but was evidently somewhat lower than 
before. 

The patient was dismissed June 20, weighing 48.1 kg., on a diet of 60 gm. 
protein, SO gm. carbohydrate, and ISOO calories, with fortnightly fast-days. 
The first blood sugar analyses were made during this period, and showed a ten- 
dency to slight hyperglycemia. 

Subsequent History. — The patient remained free from glycosuria while keeping 
house for herself. She then traveled again and gained moderately in weight. 
The traces of glycosuria which finally returned were again due to unintentional 
irregularities in diet in hotel life. 

Third Admission. — Apr. 16, 1917. Weight 46.4 kg. Heavy glycosuria, slight 
ferric chloride reaction, ammonia nitrogen 1 .96 gm. , blood sugar 0.317 per cent, CO2 
capacity 46 vol. per cent. Glycosuria continued on the diet formerly prescribed, 
but ceased with a single fast-day, Apr. 22. A carbohydrate test thereafter 
showed a tolerance of only 50 gm. The acidosis meanwhile cleared up. A 
carbohydrate-free diet was then instituted, with 65 gm. protein and 1200 cal- 
ories. On this there was an excretion of 0.8 to 1 gm. ammonia nitrogen daily. 
The last blood examination on May 23 still showed hyperglycemia of 0.176 per 
cent. The patient was discharged May 30, 1917, weighing 45.8 kg., on the diet 
above mentioned (1.4 gm. protein and 26 calories per kg.). She was to return to 
the hospital within a few months for observation to determine whether these meas- 
ures were adequate. 

Remarks. — One feature of interest is the possible origin of the diabetes from 
an infection or operation. Possibly this was no more than an exciting cause. 
At any rate, the diabetes was permanent. The case was of the most acute type 
and the progress very rapid, so that physicians had given a prognosis of only a 
few months of life. The actual result has been an approximately normal exist- 



198 CHAPTER III 

ence for SJ years to date. The principal trouble has been that the life was too 
nearly normal. Though the patient was strictly faithfiil in her intentions, she 
led a rather strenuous life and exceeded her diet quantitatively in such manner 
that the weight was not held down to the desired degree of undernutrition. The 
greatest difficulty has been the prolonged life in hotels, where undue quantities of 
carbohydrate were eaten unintentionally. Such causes of injury are very serious 
in a case inherently so severe and so susceptible to harmful influences. In addi- 
tion, there is the fact that the tendency to hyperglycemia was not detected and 
checked in its incipiency. These various causes suffice to account for the clearly 
perceptible downward progress. Comparison between the great rapidity of such 
progress before beginning treatment, and its slowness during more than 3 years 
of still imperfect treatment, casts doubt upon the existence of any "spontaneous" 
cause. The patient is stiU comfortable and looks the picture of health. The 
more rigorous dietary restrictions now necessary will reduce her considerably in 
weight and strength, and it remains to be seen whether they will succeed in 
arresting the downward tendency. 

CASE NO. 4. 

Male, age 12 yrs. American; no occupation. Admitted June 22, 1914. 

Family History. — Mother is well. Two of her grandparents died supposedly of 
Bright's disease, at age above 60. Her father died supposedly of typhoid at 
62. Her mother died of cancer of the stomach at about the same age. Her 
only brother and sister are living and well. Father's grandparents died in old 
age. Father's mother died of heart trouble at above 70 years. His father died 
after 60 with some form of nervous and mental trouble along with glaucoma. 
An uncle of the father died at the age of 6 years of diabetes. Two brothers of 
the father died, one in Europe at the age of 21, supposedly from overstudy, the 
other of some nervous or mental trouble in a sanitarium. The father is the only 
survivor of his family and is neurotic. Patient's parents married when the 
mother was 19; she had two children 13 months apart and had typhoid when 
the first baby was 1 month old; no miscarriages. The first child developed 
diabetes at the age of 2| years and died from it at 4 years. 

Past History. — Patient had normal birth. Mother's milk disagreed and baby 
was raised on artfficial food. At the age of 2 months, history of swelling of both 
sides of neck; incisions on the two sides said to have liberated enough pus to fill a 
drinking glass; no return of anything of the sort. The baby was healthy and fat, 
but not abnormally obese. Several attacks of bronchitis in infancy, "rheuma- 
tism" in the legs for 4 days when 4 years old, measles at 5, chicken-pox at 6, 
several attacks of tonsillitis thereafter, but no complaint of tonsils in recent years. 
In general a bright, healthy, active boy. He attended school for 2 years, there- 
after was taught by governess at home. Candy was forbidden from fear of 
diabetes, otherwise an ordinary diet was taken with ordinary quantities of 
starch. 



CASE RECOEDS 199 

Present Illness. — Polyuria and polyphagia began at the age of 5, and diabetes 
■was immediately diagnosed by family physician. Diet was restricted by with- 
drawal of sugars and most starches, substituting gluten bread, but through 
more than a year of such treatment patient never became sugar-free. A diabetic 
specialist was then consulted and glycosuria was kept absent for several weeks. 
Acidosis was found about this time, and a small amount of carbohydrate was then 
allowed. He remained under careful treatment up to the age of 9, but felt so 
badly and lost so much weight on carbohydrate-free diet that a change seemed 
necessary. He was then given liquid diet, taking two or three quarts of milk a 
day, but glycosuria became so heavy that strict diet was resumed within a few 
days. One such period has been tried since; otherwise a moderately restricted 
diet in weighed quantities has been taken. The usual oat cures, preceded and fol- 
lowed by vegetable days with eggs have been used repeatedly, but no fast-days. 
The patient's highest weight was 70 pounds at the age of 10. Up to the age of 
1 1 the urine had been free from albumin so far as observed. At that time both 
glycosuria and acidosis became worse, and urine showed considerable albumin and 
casts. Nephritis has been present ever since, with more or less edema most of 
the time. Vision began to be blurred several years ago and was not aided by 
glasses. About a year ago there began to be a mist before his eyes, which has 
increased to nearly total bhndness. The hair has been falling out since about 
the same time. Teeth have not decayed, but have failed to develop; two ca^- 
nines appeared about a year ago and barely protruded beyond the gums. Con- 
stipation is complained of, also attacks of vomiting. Coma has been, seriously 
threatened on two occasions and has been averted by the free use of carbohy^ 
drate and alkali. A number of different climates and mineral springs have been 
tried without result. Neuritic pains in the legs are also complained of, and on 
two occasions recently sUght superficial injuries have produced long-standing 
ulcers, one of which is barely healed. The gums are said to bleed whenever the 
teeth are washed. The patient has been bed-fast for a month or more on ac- 
count of weakness, but recently has been sitting up and dressed for a few hours 
daily. 

Physical Examination. — Height 140 cm., weight 23.8 kg. Extreme emacia- 
tion and weakness. Hair cream-colored, long, silky, thin. Eyelids droop with 
look of exhaustion; intraocular tension diminished. Pupils react to both light 
and distance, but tests of vision show that only marked changes in illumination 
are perceived and only large objects dimly distinguished. Vision better at 
periphery than at center of fields. Ears and nose normal. Mouth shows above 
mentioned condition of teeth, well kept, but tongue moderately coated. Palate 
and fauces narrow; only slight tonsillar enlargement. Palpable glands in neck, 
very small. A few sudamina especially on sides of neck. Otherwise skin is dry 
and slightly scaly. Knee jerks barely obtainable, other reflexes normal. General 
examination otherwise negative. 

Treatment. — On June 23 and 24 diet was permitted according to description of 



200 CHAPTER in 

what had previously been taken. Fasting was begun with some misgivings on 
account of the extreme weakness, and whisky was administered in the small 
quantities which the patient could take without complaint of discomfort. By 
June 27 the strength seemed greater rather than less. Nevertheless as a pre- 
caution, since fasting had not heretofore been imposed upon any patient as danger- 
ously weakened as this, it seemed conservative on this day to allow 155 gm. 
olive oil with a trifle of vegetables as a rehsh. Alcohol was given the next day, 
and on the following days olive oil was again added. Green vegetables were then 
added, representing carbohydrate as follows: July 1, 6 gm.; July 2, 12 gm.; July 
3, 15 gm. A change was then made to protein-fat diet, increasing up to 61.6 
gm. protein and 1530 calories on July 13. Pancreas was fed at this time as noted 
below. This diet was tolerated as far as glycosuria was concerned. The bare 
traces of glycosuria Umited to certain portions of the day, which appeared so en- 
tirely unaccountable at that time, were explained subsequently as due to sur- 
reptitious eating, in this instance probably of a sweetened tooth-paste. On ac- 
count of these traces of glycosuria and the persistent acidosis, an absolute fast 
was imposed notwithstanding weakness, and continued for 5 days, being followed 
by the alcohol day of July 19, and then by a limited protein-fat diet, always below 
900 calories. By the end of this period, Aug. 7, the strength was far better than 
at any previous time. The patient was up and dressed most of every day, 
walked about the hospital, and on Aug. 7 was strong enough for an automobile 
ride. Beginning Aug. 9, a period of very low diet consisting largely of alcohol 
and green vegetables was instituted, particularly for the purpose of clearing up 
acidosis, until on Aug. 17 one egg was added to the whisky and vegetables. The 
diet was increased by one egg daily, tiU on Aug. 20 four eggs were given. After 
a fast-day with alcohol on Aug. 24 and a vegetable day on Aug. 25, protein-fat 
diet was begim and rapidly increased to 1600 to 1700 calories, with as much as 
SO to 60 gm. protein. Glycosuria was stopped by the fast-days (with alcohol) of 
Sept. 5 and 6, but returned promptly with resumption of the high diet. It also 
persisted during the 2 alcohol days, Sept. 16 and 17, and the low protein-fat diet of 
SOO calories or less of the latter part of Sept. and the &st of Oct., but cleared up 
■when a diet was subsequently given composed of little more than alcohol and 
olive oil. The patient became very weak in consequence of this undernutrition. 
On Oct. 19 he woke up weak, but with normal consciousness. While he was 
eating breakfast consciousness gradually failed, and within less than an hour he 
was entirely unconscious. Pulse and respiration showed no special change. 
Tube feeding was instituted, a total of nine eggs and 30 cc. whisky being given in 
divided doses. Saline solution was given intravenously at intervals, and three 
doses of 10 gm. levulose each in 200 cc. solution were given subcutaneously. Bene- 
fit was only temporary, and death occurred after very gradual decline on Oct. 
20, with continued imconsciousness but no other signs of diabetic coma and with 
urine negative for both sugar and acetone bodies. 
Acidosis. — The patient entered with a daily excretion of approximately 18 gm. 



CASE RECORDS 



201 



total acetone bodies (as |8-oxybutyric) and 2.5 gm. ammonia; these were brought 
gradually to an almost normal level. A slightly high ammonia and occasional 
traces of ferric chloride reaction persisted. Radical treatment of the acidosis 
was difficult because of the extreme weakness of the patient. 

The results of attempting to maintain strength by the use of fat are shown in 
Table V. 

Oil days instead of fast-days were tried at the outset as shown, because of their 
use by former workers and because of the patient's weakness. The first and 



TABLE V. 





Diet. 


1 

fe. 


6 

S 

3 

o 
gm. 


4J 

u 

i 


Urine. 


Date. 


1 


i 


1 

1 


1 


1 


i 

I 

CC. 


i 


1 
*3 

3 


1 


U (A 

Hi >, 

III 


1914 


em. 


gm. 


gm. 


gm. 


gm. 


gm. 


gm. 


gm. 


June 23 


70.5 


101 


4.15 


— 


1623 


23.8 


— 


— 


3174 


42.51 


11.59 


1.65 


8.00 


" 24 


91.5 


177 


103.3 


— 


2319 


23 .'2 


— 


— . 


2772 


32.60 


10.64 


3.44 


15.59 


" 25 


— 


— 


— 


16.5 


116 


23.2 


3 


— 


2953 


12.96 


6.67 


2.75 


9.22 


" 26 


— 


— 


— 


19.5 


137 


22.3 


— 


— 


2361 


6.85 


5.15 


2.60 


7.67 


" 27 


6.9 


248 


11.9 


1.2 


1578 


22.4 


— 


— 


2028 


16.30 


5.17 


2.33 


17.81 


"" 28 


2.3 


2.3 


1.9 


25.5 


189 


21.2 


20 


. — 


2074 


8.90 


5.68 


2.70 


8. 95 


" 29 


— 


50.0 


— 


26.0 


632 


22.0 


— 


5 


2238 


1.17 


3.18 


1.80 


2.99 


" 30 


— 


80.0 


— 


22.0 


874 


21.6 


— 


20 


2483 





3.50 


1.79 


4.77 


July 1 


2.1 


102.6 


5.8 


20.0 


1125 


21.6 


— 


20 


2153 


+ 


3.61 


2.37? 


3.25 


" 2 


5.3 


110.0 


12.7 


10.0 


1201 


21.0 


— 


5 


1589 


0.66 


3.18 


2.07 


2.10 


" 3 


4.5 


12.5 


15.3 


22.5 


353 


21.4 


— 


— 


1324 


3.92 


2.70 


1.32 


4.35 


" 4 


7.6 


38.0 


— 


21.2 


532 


21.6 


— 


— 


1501 


-1- 


3.33 


1.08 


7.03 


" 5 


15.4 


12.1 


— 


11.2 


625 


21.2 


— 


— 


1340 


0.80 


3.08 


2.20 


8.19 


" 6 


15.4 


52.1 


— 


17.5 


669 


21.6 


— 


— 


1574 


0.97 


2.44 


1.65 


4.35 


" 7 


22.6 


58.1 


— 


17.5 


731 


21.4 


— 


— 


2855 


0.36-1- 


5.47 


1.62 


7.45 


" 8 


22.6 


58.1 


■ — 


17.5 


731 


21.8 


— 


20 


1736 


-1- 


2.83 


1.15 


7.23 


u 9 


22.6 


58.1 


— 


17.5 


731 


22.6 


— 


— 


2453 


-t- 


3.48 


1.52 


5.80 


" 10 


22.6 


58.1 


— 


17.5 


731 


22.8 


— 


— 


2749 


+ 


3.33 


1.48 


5.87 


" 11 


30.8 


82.2 


— 


17.5 


1012 


23.2 


— 


— 


2769 


+ 


3.75 


1.47 


11.66 


" 12 


30.8 


82.2 


— 


17.5 


1012 


23.4 


— 


20 


2467 


+ 


4.29 


1.26 


6.26 


" 13 


61.6 


124.4 


— 


17.5 


1531 


23.2 


— 


18 


2768 


+ 


7.94 


1.55 


6.28 


« 14 


Fast-day. 




— 




23.5 


— 


— 


1031 


-t- 


3.25 


0.59 


3.37 


" IS 


u 




1.5 




23.0 


— 


— 


1082 


0.46 


2.49 


0.62 


4.92 


" 16 


iC 









22.6 


— 


— 


1225 


0.22 


2.47 


0.70 


3.24 


" 17 


(t 









22.0 


— 


— 


1263 





"2.70 


0.69 


0.79 


" 18 


tt 









21.6 


— 


— 


1130 





1.92 


0.28 


1.46 


" 19 


u 




12.0 




21.6 


— 


— 


1322 





1.98 


0.27 


1.09 



202 CHAPTER m 

largest of such fat rations, on June 27, caused the acetone body excretion to rise 
suddenly from 7.67 to 17.81 gm. The next day, without fat, there was an equally 
sudden fall to 8.9S gm. The influence of smaller quantities of fat on subsequent 
days was less clearly distinguishable, but the general effect was an elevation 
of the ammonia and acetone body output, as shown especially by the fall with 
fasting after July 13, It is thus evident that even moderate quantities of in- 
gested fat keep up acidosis, presumably by maintaining a higher fat metabolism 
than on fasting. Also, strength is not improved by such use of fat. On the 
contrary, acidosis tends to produce more marked asthenia than undernutrition. 
The occasional alkali dosage is shown in Table V. Perhaps the reason for the 
absence of increase of ammonia excretion with the high fat intake of June 27, is 
that the ammonia formation was already at the maximum possible in this patient 
at this level of total nitrogen excretion. Possibly the lack of neutralizing sub- 
stance was responsible for the marked clinical symptoms of acidosis (hyperpnea, 
prostration, small rapid pulse) which came on promptly toward the close of 
that day. It therefore seemed advisable to give 20 gm. sodium bicarbonate 
on the next day. Calcium carbonate might theoretically neutralize acid in the 
stomach and perhaps to some extent in the intestine. It is not known whether 
it served any practical usefulness in this or other cases where it has been tried. 
No other alkali was given except toward the close of the history; then on 6 days 
(Oct. 8 to 13) without s3rmptoms suggesting acidosis and merely with a vague 
idea of guarding against salt starvation, the following mixture was given daily: 
sodium bicarbonate, calciimi carbonate, magnesium oxide, each 2 gm., potassium 
bicarbonate, 1 gm. The giving or withholding of such mixtures has had no per- 
ceptible influence upon this or other patients. Vegetables presumably furnish 
sufficient quantity and variety of bases. 

Tolerance. — This was exceedingly low, but an exact estimate of it is prevented 
by slips in the diet. At the outset, the barely perceptible traces of glycosuria 
in the early days of July seemed perplexing. Later, unaccountable glycosuria 
was encountered on certain days without clear relation to the known food in- 
take. It had seemed that a blind boy isolated in a hospital room and so weak 
that he could scarcely leave his bed would not be able to obtain food surrepti- 
tiously when only trustworthy persons were admitted. It turned out that his 
supposed helplessness was the very thing that gave him opportunities which 
other persons lacked. Even on a diet which satisfied his appetite according to 
his own statement, as at the end of Aug. and the first of Sept., the attempt to 
evade the strict watch kept over him appealed to him as a sort of game or battle 
of wits, so that he even took things for which he had no real desire. Among these 
unusual things eaten were tooth-paste and bird-seed, the latter being obtained 
from the cage of a canary which he had asked for. Also his mother and his 
governess on visiting him sometimes brought lunch, which was kept in a closet 
supposedly without his knowledge; nevertheless, in the short intervals when he 
was unwatched, he managed to find it and remove such articles as might not be 



CASE RECORDS 203 

missed. These facts were obtained by confession after long and plausible denials. 
The experience illustrates what great care is necessary if records of diabetic 
patients are to be vouched for as correct. 

Weight and Nutrition. — Weight at admission 23.8 kg., at discharge 18.1 kg. 
One feature is the successful carrying through of two periods of inanition in a 
dangerously weak, small boy. The olive oil, as mentioned, probably did more 
harm than good. The whisky may have been of some slight aid, but there was no 
plain clinical evidence. The 6 days of almost complete fasting beginning July 14 
were borne without signs of collapse, even though the weakness was such as to 
cause concern before any fasting was imposed. The diet of some 700 to 800 cal- 
ories, protein, fat, and alcohol, in the latter part of July and the first part of 
Aug., was theoretically sufficient for maintenance, but was barely tolerated. 
Even though some of the glycosuria may have been due to slight errors in diet, 
the recurring traces of ketonuria show that this intake was excessive. The 
period of carbohydrate and alcohol beginning Aug. 9 cleared up the ketonuria, 
but did not avail to prevent its prompt return when a high carbohydrate-free diet 
was next attempted. The diet of 1600 to 1700 calories at this time was very 
high for this body weight; there was in fact a slight gain of weight and strength, 
but as usual the increasing glycosuria and ketonuria forced a cessation of this 
plan, and the end-result, as is invariably the case, was harmful instead of bene- 
ficial. The subsequent undernutrition beginning Sept. 16 was improperly planned, 
because the persistent glycosuria apparently indicated a remarkable absence of 
assimilation, whereas the real trouble was the unusual ingenuity of the patient in 
obtaining forbidden food. 

Pancreas Feeding.— This patient developed a liking for raw pancreas, so that he 
spontaneously asked for it. It was therefore of interest to study the effect of a 
diet in which pancreas protein was the sole possible source of sugar; i.e., a diet 
composed of nothing but pancreas, olive oil, and alcohol. This was the character 
of the diet beginning July 4; on that day SO gm. of fresh pancreas weregiven as 
the only protein. The next day this was increased to 100 gm., which continued 
to July 7, when it was raised to 150 gm. This continued to July 11, when it was 
increased to 200 gm. On July 13 the quantity was increased to 400 gm. The 
traces of glycosuria were not cleared up either by pancreas or by fasting until 
the patient's trick of eating a small quantity of tooth-paste each morning was 
detected, whereupon on July 17 the traces of sugar ceased promptly. It is there- 
fore evident that pancreas feeding did not avail to establish an assimilation for 
even the trivial quantity of sugar contained in a very few grams of tooth-paste. 
On July 20, after fasting, the first diet given consisted of 80 gm. fresh beef pancreas 
with whisky and olive oil. On July 21 the pancreas was increased to 120 gm. 
On July 22 it was only 96 gm. by mistake, on July 23, 120 gm. On July 24 and 
25 the identical diet was given, with substitution of raw beef for pancreas. On 
July 26 and 27 the same quantity of beef was given, cooked before eating. On 
July 28 and 29, 120 gm. of raw pancreas were again substituted. The occasional 
glycosuria up to this time was irregular and probably due to surreptitious eating. 



.204 CHAPTER in 

This diet was apparently near the verge of tolerance. After a fast-day on July 
30 the same diet was given, of 120 gm. pancreas with addition of one egg; this diet 
continued to Aug. 8. A regular and persistent glycosuria was the result, evidently 
■due to the fact that this diet was slightly in excess of the tolerance. It would 
therefore appear that fresh pancreas was not able to increase the patient's protein 
tolerance to the extent of one egg, since he was mostly sugar-free on pancreas or 
raw or cooked beef without the egg, and excreted small quantities of sugar on raw 
pancreas with addition of the egg. There was also no perceptible influence upon 
acidosis. Another pancreas feeding experiment was tried, begiiming Sept. 10, 
with similar result (see Chapter IV). 

Remarks. — This 12 year old patient, admitted after 7 years of downward prog- 
ress, delayed but not stopped by the most competent care obtainable, with reti- 
nitis and profound emaciation and weakness, may be said to have been in the hope- 
less stage of his disease. It is of interest that both albumin and casts cleared up 
under treatment; they may therefore be attributed to the diabetes or perhaps 
:to the acidosis, since true nephritis does not thus disappear. The weight was 
reduced by 5.8 kg. in the 4 months of treatment. The improvement in strength 
was evident to all concerned and considerable encouragement was felt at one time. 
The essential difficulty lay in the stealing of food; on account of this deception 
the treatment was improperly managed in several respects. The undernutrition 
period of the closing month was what brought on death, which may be attributed 
to inanition. 

It seems unprofitable to speculate how long or in what condition this patient 
might have hved if he could have been treated by undernutrition from the first 
-diagnosis of diabetes. What is certain, however, is that diabetic retinitis has 
never yet been known to develop under thorough treatment by this method; and 
anyone making use of high diets for the sake of supposed comfort must be pre- 
•pared to assume responsibihty for occasional blindness and similar troubles. 

CASE NO. 5. 

Male, married, age 34 yrs. American; customs inspector. Admitted July 
15, 1914. 

Family History. — Entirely negative for heritable or metabolic disease. 

Past History. — Generally healthy life. Measles, tonsiUitis, and adenoids in 
childhood. Neisser infection at 22. No history or indications of syphiUs. Ner- 
vous and easily excitable since boyhood. Indigestion and constipation began at 
about 22 and have grown worse up to the present, probably aggravated by irregu- 
lar eating since entering customs service at 23. There is a feeUng of hunger with 
nausea between meals, temporarily relieved by eating; no pain, no vomiting, little 
• eructation. No alcohol up to 25, then began to drink beer and other liquors, 
occasionally to sUght excess; during the past 4 months has lost all appetite for 
liquor. Smokes two or three cigars a day. 

Present Illness.— In July, 1913, while at work, patient experienced a sudden 
-feeling of dizziness, then compression about chest, followed by vomiting, colic, 



CASE RECORDS 205' 

and diarrhea. After a doctor had given him calomel and salts at home, on diag- 
nosis of "autointoxication," he had hot fever during that night, but felt well the 
next day and returned to work. Urine was not examined. From that time on 
he felt constantly thirsty and steadily lost weight and strength. About Sept. 1 
the same doctor was consulted again and found 4 per cent glycosuria. Patient 
followed the routine restricted diet prescribed, but was sugar-free only twice for 
about a week; this sugar-freedom was obtained by rigid exclusion of carbohydrate. 
Acetone appeared, so a small quantity of carbohydrate was allowed, with result- 
ing glycosuria. Occasional vegetable days have been employed. Lately a quart 
of mUk daily has been added, and diet has been unrestricted on 1 day each week.. 
On vacation in the country, July of this year, he took ordinary mixed diet for 1 
week, and experienced an acute attack similar to the initial seizure 1 year pre- 
viously. At present he follows the diet with restricted carbohydrate; feels ner- 
vous and weary, no polyphagia, slight polydipsia and polyuria; no dryness of skin, 
but on the contrary troublesome sweats. Normal weight has been 175 to 18& 
pounds; recently it has fallen to 144 pounds. 

Physical Examination. — Height 1 73.8 cm. Weight 60.4 kg. Body well formed, 
but lean. Neurasthenic manner, expression indicating weakness and weariness. 
Skin very moist, noticeable pallor. Slight enlargement of tonsils. Knee jerks- 
entirely absent. Other reflexes normal. Examination otherwise negative. 

Treatment. — On the day of admission and the 2 following days, patient was 
allowed to choose a diet resembling his habitual one. Then 2 plain fast-days were 
given, followed by 3 alcohol days. The result, as shown in the graphic chart, 
was a clearing up of glycosuria but persistence of the ferric chloride reaction. 
Green vegetables were then added (July 23 to 27) and the latter reaction thus 
cleared up. After a single fast-day with alcohol on July 28, the patient proved 
able to tolerate a diet as high as 1100 calories with about 50 gm. protein and 70 
to 75 gm. carbohydrate. This was undernutrition, representing, for a body weight 
of about 60 kg., about 0.9 gm. protein and less than 20 calories per kg. Alcohol' 
was discontinued on Aug. 5, as it was unnecessary and the formation of a habit 
was undesirable. Beginning Aug. 11, an experimental period was begun to show 
the effect of increasing calories, particularly in the form of fat (see below) . There- 
after, it was intended to place the patient upon a proper hving ration preparatory 
to dismissal; but on Nov. 9 he suddenly requested discharge to accept a particu- 
larly favorable business opportunity. He was therefore allowed to go with 
approximate instructions regarding diet, following the plan of not weighing his- 
food but judging portions by the eye, and guiding himself by his urinary tests and 
particularly by his weight. The diet ordered consisted of protein, fat, and about 
100 gm. carbohydrate in green vegetables. The entire treatment was not one of 
undernutrition, because he left weighing approximately 1 kg. more than on adibis- 
sion to hospital. The relative mildness of the diabetes had not called for the- 
most rigorous measures, and the patient was already far under normal weight.. 
He was instructed never to allow himself to gain weight above 160 pounds. 



206 



CHAPTER lU 



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CASE RECORDS 



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~F^ 


VO 


00 




iO 


■*. 


m 


00 




'■ ro 


o\ 


t^ 


CM 


d 




1-1 


i-H 


»— 1 




iH 




: + 

, + 

+ 


+ + 








+ + + 
+ + + 
+ + + 






+ + 








CO 


tn 


,_f 









00 


tr^ 


00 


CO 







I d 


00 


CM 


vd 




: lO 


VO 




CO 






^-H 


»— < 


CM 








»o 


10 


l^ 


"0" 






n 


J^ 


VO 


CM. 






o 


CO 


y-t 









j 


CO 


CO 


CO 






i ^ 


00 


■*. 


CM 






^ 


*-l 


»H 


CM 






VO 


>o 


VO 


3 






' "^ 


"0" 


"5" 








•rj 


a\ 


o\ 


1 


1 




o 














tH 


1-^ 


*H 








lO 


10 


t^ 





















s 


\0 


§ 








o 


CM 


vH 








o 


o\ 


o\ 








^ 












Ov 


CN 


CN 


; 






t^ 


T-H 


T-( 


X 






lO 


\o 





i 


^^ 














o 


>o 


in 


en 






<^ 


»o 


10 


r^ 








t-4 


i-i 


^ 






a 


<o 





1^ 


00 o\ 


^ 


CM 


CM 


CN 


<N 


CS C^ re 




4J 










, 


D, 










•4-1 


0} 













CO 














r.\v^ 



vofu^ 



v-^>i'i^'i^/. 






TABLE VII. 





Diet. 




Urine. 


J 


OJ 


Date. 






, 


« . 


tn U) 








1 


'Sd 


^ 

S 


I.S 




.3 
S 
2 


IS 


II 


3| 


la 


i 


'o 


^ 




11 




II 




Ph 


\^ 


u 


H 


u 


is. 


> 


CO 


& 


H 


|2! 


u 


1914 


««. 


em. 


gm. 


cc. 


gm. 




em. 






Sept. 29 


26.4 


7.3 


82.0 


511 


8.7 


58.8 


1375 


+ 


+++ 


8.06 


-4.13 


+82.0 


" 30 


26.3 


7.2 


82.2 


511 


8.5 


60.0 


1975 





+++ 


10.51 


-6.69 


+82.2 


Oct. 1 


26.2 


5.9 


75.6 


471 


7.7 


60.8 


3035 





+++ 


6.80 


-2.89 


+75.6 


" 2 


25.7 


7.3 


80.9 


513 


8.4 


60.6 


2900 


+ 


++ 


5.92 


-2.10 


+80.9 


" 3 


26.1 


7.4 


80.4 


504 


8.3 


60.6 


2995 





+++ 


8.69 


-8.98 


+80.4 


" 4 


24.4 


6.6 


82.5 


499 


8.3 


60.0 


2715 





+ 


7.06 


-3.43 


+82. S 


" 5 


32.5 


13.0 


80.0 


582 


9.6 


60.2 


3380 





+ 


9.06 


-4.22 


+80.0 


" 6 


40.1 


16.8 


73.2 


620 


10.3 


60.0 


3195 








8.56 


-2.69 


+73.2 


« 7 


44.9 


57.8 


80.1 


983 


16.3 


60.0 


2315 


+ 





— 




+80.1 


" 8 


45.5 


51.6 


84.3 


1010 


16.5 


61.0 


2590 








8.38 


-1.61 


+84.3 


" 9 


46.1 


51.7 


82.3 


1006 


14.7 


61.4 


3205 








8.46 


-1.58 


+82.3 


" 10 


45.5 


51.6 


84.3 


1010 


16.4 


61.6 


2615 





+ 


7.95 


-1.17 


+84.3 


" 11 


51.5 


56.3 


82.6 


1072 


17.3 


62 jO 


2795 








— 




+82.6 


" 12 


S8.7 


61.8 


77.0 


1129 


18.1 


62.4 


2960 








8.88 


-0.14 


+77.0 


" 13 


65.2 


96.0 


82.0 


1495 


23.6 


62.2 


2822 





+ 


8.81 


+0.98 


+82.0 


" 14 


69.1 


128.5 


82.1 


1814 


29.1 


62.4 


3150 








9.45 


+0.83 


+82.1 


" 15 


75.2 


163.2 


82.1 


2161 


34.4 


62.8 


3145 








9.12 


+2.05 


+82.1 


" 16 


75. 5 


187.3 


82.4 


2392 


38.1 


62.8 


2895 








7.30 


+3.84 


+82.4 


" 17 


81 


189 


105 


2518 


39.9 


63.0 


4280 








9.93 


+2.11 


+ 105.0 


" 18 


92 


196 


104 


2621 


41.6 


63.0 


3380 








8.92 


+4.76 


+ 104.0 


" 19 


104 


195 


99 


2643 


41.9 


63.0 


3270 








10.20 


+5.27 


+99.0 


" 20 


103 


194 


103 


2647 


41.7 


63.4 


3960 








11.56 


+3.78 


+ 103.0 


" 21 


104 


195 


103 


2661 


42.0 


63.4 


3160 








10.49 


+4.99 


+ 103.0 


" 22 


110 


203 


124 


2851 


45.0 


63.4 


4070 





+ 


— 


+5.38 
(calc.) 


+ 124.0 


" 23 


114 


197 


121 


2646 


41.7 


63.4 


3680 








11.48 


+s:49 


+ 121.0 


" 24 


114 


220 


118 


2999 


47.0 


63.8 


4254 








15.31 


+ 1.64 


+ 118.0 


" 25 


114 


228 


120 


3073 


48.4 


63.4 


4085 








15.36 


+ 1.61 


+ 120.0 


" 26 


113 


219 


119 


2829 


44.7 


63.2 


4487 








14.36 


+2.47 


+ 119.0 


" 27 


115 


221 


123 


3128 


50.0 


62.8 


3590 





+ 


_ 





+ 123.0 


" 28 


112 


227 


118 


3053 


48.3 


63.2 


3810 








_ 





+ 118.0 


" 29 


114 


228 


120 


3074 


48.8 


63.0 


3554 





+ 


_ 





+ 120.0 


" 30 


81 


222 


39 


2556 


— 


— 


1605 








_ 





+39.0 


" 31 


78 


368 


51 


3950 


— 


— 


930 





+++ 


_ 





+51.0 


Nov. 1 


108 


193 


92 


2610 


39.4 


62.2 


3770 














+92.0 


" 2 


148 


292 


92 


3676 


59.8 


61.4 


3205 





+ 


_ 





+92.0 


" 3 


165 


483 


104 


5595 


90.8 


61.6 


2865 


+ 


++ 


_ 





+104. 


" , 4 


165 


482 


99 


5563 


89.4 


62.2 


2600 


+ 


+ 





, 


+99.0 


" S 


112 


351 


93 


4099 


65.9 


62.2 


3090 





+ 





_ 


+93.0 


" 6 


Alcohol 2C 


'gm. 


140 




61.6 


2690 















" 7 


155 


221 


119 


3177 


53.6 


59.2 


2240 











_ 


+ 119.0 


" 8 


114 


220 


120 


3002 


48.8 


61.4 


3880 











_ 


+120.0 


" 9 


114 


220 


120 


3002 


49.0 


61.2 


1710 








- 


- 


+ 120.0 



208 



CASE RECORDS 209 

Overfeeding Experiments. — The patient was peculiarly adapted to experiments 
with excessive diets, for though he had never suffered from true diabetic poly- 
phagia, he was habitually a very heavy eater. Also his constipation was invinci- 
ble, notwithstanding the most enormous fat diets. He took these diets with 
relish and without increase of his slight dyspeptic complaints. As indicated in the 
laboratory chart, the stools were small, hard, and infrequent, and carmine for de- 
marcation was always retained for several days. With the return of diabetic 
symptoms in each instance the patient felt so much worse that he was glad to re- 
sume a rational diet even at the price of slight continual hunger. The experi- 
ments were of practical usefulness in convincing him of the inadvisability of try- 
ing to satisfy his appetite, and with this object lesson he has remained faithful to 
treatment from that time to the present. 

Nitrogen Balance. — The most surprising feature is the remarkable nitrogen 
retention, comparable to that described in normal persons by Liithje and in dia- 
betics by Falta and coworkers. It is to be recalled that the patient was moderately 
emaciated from diabetes and had then been subjected to fasting and low diet, 
which had reduced his nitrogen excretion to a low level. Also the diet ia this ex- 
periment was liberal in protein, and starting at 64.5 calories per kg. increased to 
109 calories per kg. — an extreme surplus for a man at rest in a hospital ward. 
With the rapid gain in weight it is not surprising that considerable nitrogen was 
stored, but it is remarkable that the low output of 6 to 8 gm. daily was main- 
tained up to the sudden increase on Sept. 13, the day before the onset of glyco- 
suria, and simultaneously with the appearance of the first decided ferric chloride 
reaction. The retention then continued, but to a diminishing extent, notwith- 
standing the steady increase in total calories. The diminution of storage may 
probably be attributed to the active diabetic symptoms. Notwithstanding the 
large quantity of nitrogen stored, the fasting and low diet following Sept. 27 
quickly brought a return to the same low nitrogen output as before. Analyses 
are not complete for the second period of overfeeding, but the data available 
fuUy confirm the results in the first period. 

Influence of Body Weight. — The weight was built up in two feeding periods on 
different diets. Diabetic symptoms were present at the higher weight in each 
instance. The attainment of a higher weight in the second as compared with 
the first period of overfeeding may have been aided by the mildness of the symp- 
toms on the second diet. This difference makes it clear that weight was not 
the sole factor in bringing back symptoms, but the kind and quantity of the 
different elements of the diet is necessarily an important factor. 

Influence of the Diet. — Both glycosuria and acidosis were brought on by in- 
crease of the diet, particularly in fat. The influence of the three elements may 
be considered as follows. 

1. Carbohydrate. — The glycosuria cannot be attributed merely to carbohy- 
drate, because the increase of carbohydrate in the first overfeeding period was 
not great, and the quantity on certain days, such as Sept. 23, 25, and 26 with 



210 CHAPTER in 

heavy glycosuria was actually less than on earlier days without glycosuria. Also 
in the second overfeeding period the carbohydrate was regularly higher than in 
the first one, yet glycosuria was trivial in comparison with the first period. On 
the other hand, carbohydrate was not effectual in preventing acidosis, so that 
it would have been impossible, even in this relatively mild case, to control acidosis 
by feeding carbohydrate along with a high fat diet. A fallacy of the carbohydrate 
balance plan is also illustrated; for in the period Sept. 11 to 19 this balance was 
as high as before, yet the beginning ferric chloride reactions and the higher average 
acetone excretion, though so slight as to be often ignored, were actually significant 
of the damage already done by fat and soon to be more manifest. 

2. Protein. — Protein was increased at the time of glycosuria and acidosis in 
the overfeeding period. Such increase did not prevent acidosis. The gener- 
ally higher protein may be regarded as one cause of the heavy glycosuria in the 
first overfeeding period, as compared with the slight glycosuria in the second. 
On the other hand, protein can scarcely be credited as the sole cause of the gly- 
cosuria, since the latter was out of proportion to the increase of protein in the 
first overfeeding period, and also on certain days of the second period {e.g. Nov. 
3 and 4), with sUght glycosuria, both protein and carbohydrate were higher than 
on certain days in the first period {e.g. Sept. 20, 23, 25, and 26) with very heavy 
glycosuria. 

3. Fat. — The principal increase in the diet was in the form of fat, and to this 
may be attributed most of the gain in weight and return of all diabetic symp- 
toms. The fat diet was much higher in the first than in the second overfeeding 
period, and the excessive caloric intake in this form may be considered the most 
important factor in the production of both glycosuria and acidosis. Periods of 
fasting and lower diet quickly cleared up both the laboratory and the clinical 
symptoms. 

4. Calorimetry. — ^This patient was studied by Dr. Eugene DuBois in the 
respiration calorimeter of the Russell Sage Institute of Pathology on Oct. 30 and 31 
and Nov. S, with a view to observing any possible anomalies in the disposal of 
the huge rations, particularly of fat. No departures from the normal were demon- 
strated either in the basal metabolism or in that following a heavy fat meal.' 

Subseqiient History. — ^The patient remained at work in excellent condition, until 
he reported at the hospital on Dec. 28 weighing 160 pounds, glycosuria having 
come on with the increase in weight without change in the prescribed diet. Fast- 
ing and reduced diet at home brought him down to 157 pounds, but a trace of 
sugar returned on Jan. 10. He was therefore instructed to keep his weight there- 
after below 155 pounds. He then remained continuously sugar-free until he re- 
ported at the hospital on Mar. 21 with the following history. On account of 
his slight indigestion he had consulted a well known stomach specialist of New 
York, who told him that he must omit most of his vegetables and take two white 

1 Cf. Allen, F. M., and Du Bois, E. F., Arch. Int. Med., 1916, xvii, 1010-1059. 



CASE RECORDS 211 

rolls daily. The patient objected that this would bring back his glycosuria, 
but the physician responded that he had better have glycosuria and feel better. 
The patient therefore took the white rolls for a short time, and promptly showed 
heavy glycosuria. He then on his own judgment stopped the rolls, cleared up the 
glycosuria by fasting, and reported at the hospital because his tolerance had 
been lowered and he now showed traces of sugar on the diet on which he was for- 
merly sugar-free. A reduction of his green vegetables was therefore ordered, and 
he was instructed not to exceed his existing weight, which was then ISO pounds. 
At this weight he was reasonably weU nourished and fully able to work, and his 
troubles were all classified as neurasthenic. 

On Apr. 2 and again on Apr. 9, the patient reported, showing both sugar and 
ferric chloride reactions and weighing 149 pounds. The vegetables were ordered 
thrice boiled so as almost entirely to exclude carbohydrate from the diet, and the 
quantities of food were now more strictly regulated so as to make a ration of 
approximately 2500 calories. 

On June 19, the ferric chloride reaction was negative, but there had been traces 
of glycosuria from time to time. 

On July 13, he returned with a similar report, but had recently caught cold, 
and this had brought a return of glycosuria, concerning which he was very nerv- 
ous. He was therefore readmitted to the hospital for the week July 13 to 19 
for purposes of instruction. Physical examination was as before, except for en- 
largement of the hver to 5 cm. below costal margin. He was placed on a diet 
of approximately 2100 calories, with 90 gm. protein and 30 gm. carbohydrate 
(see graphic chart). He was discharged with instructions to weigh all food, 
adhere rigidly to this diet, and take a fast-day once every week. 

On Aug. 8, he weighed only 58.8 kg., and complained of weakness, weariness, 
and hunger, but had shown no sugar since leaving hospital. Bran muffins were 
added to relieve both his feeling of emptiness and his constipation. 

On Feb. 28, 1916, the report was similar. He was walking 6 mUes daily for 
exercise. On this basis his diet was increased to 108 gm. protein, 30 gm. carbohy- 
drate, and 2400 calories. Thereafter he continued at work with favorable re- 
ports until June 5, when the carbohydrate was increased to 40 gm. and the cal- 
ories to 2500. Traces of glycosuria gradually came on, so that on July 17 the 
carbohydrate was again reduced to 30 gm. 

The urine subsequently remained free from both sugar and ferric chloride 
reactions, and the patient gradually increased his exercise to 8 miles of walkiag 
daUy. 

On May 23, 1917, the weight was 56 kg., the blood sugar 0.116, and the car- 
bon dioxide capacity of the plasma 59.9 per cent. 

On June 13, 1917, the weight was still 56 kg. and diet was 20G0 calories, with 
50 gm. carbohydrate and 70 gm. protein. The blood sugar was 0.155 per cent, 
and the carbon dioxide capacity of the plasma 64 per cent. The urine remained 
negative for sugar and ferric chloride reactions. 



212 CHAPTER III 

Remarks.— This was one of the early cases, and the treatment contained errors 
accordingly. The diabetes was of moderate severity, and the attempt was made 
to treat it with as little inconvenience to the patient as possible, insisting upon 
a normal urine and a moderately reduced body weight, and hoping for a recovery of 
assimilation under these conditions. The result shows that such loose methods 
are not advisable even in a case of this type, and that tolerance is lost rather than 
gained under such a plan. The patient had felt unable to work at the time of his 
first admission to hospital. He has been kept in working condition during most 
of the time for 3 years. His tolerance has fallen sUghtly, so that now about 
80 gm. carbohydrate is tolerated with a diet of 2200 calories. The blood sugar was 
never reduced to normal, as might easily have been done, and the slight downward 
progress seems to be nothing inherent in the nature of the condition, but rather 
due to the inadequacy of the treatment and the continuous shght overtaxing of the 
assimilation. On the whole, a prolonged and conscientious attempt was made to 
treat this case from the standpoint of immediate comfort and efficiency, and the 
record is now believed to show that this treatment is unjustifiable even for a case 
apparently as well suited for it as this one. 

Recent examinations have shown that the liver, which was normal in out- 
line at the first examination, and afterward was obviously enlarged in examinations 
by different observers several months apart, is now distinctly subnormal in size. 
The superficial veins of the abdomen are becoming prominent. The diagnosis 
of cirrhosis seems evident, progressing through the hypertrophic to the atrophic 
stage. This has not suppressed the diabetes and dietary care should not be 
remitted, but the most rigorous measures appear unnecessary. The frequency of 
pancreatitis in connection with cirrhosis of the liver is worthy of investigation. 

CASE NO. 6. 

Female, married, age 48 yrs. Italian; housewife. Admitted July 23, 1914. 

Family History. — Indefinite. Patient is ignorant of any special disease in 
family. (Husband, short and obese, is said to have developed mild diabetes 
siince this patient's discharge.) 

Past History. — Very healthy life. Patient keeps house for her husband and 
four children. Six children died young, perhaps because of tenement conditions. 
One of those living is mentally defective. Menses regular up to 1 year ago, 
absent since. She drinks four glasses of beer, one cup of coffee, and one cup of 
tea a day. Other habits are those of an industrious poor Italian woman. 

Present Illness. — Patient was admitted on the pneumonia service on July 23, 
1914. 

Physical Examination. — ^A short, slightly obese woman with sturdy peasant 
appearance, and normal on physical examination except for consoHdation and 
pther signs of pneumonia of right lower lobe. The urine showed heavy sugar and 
ferric chloride reactions, though there had been no former complaints indicating 
diabetes. 



CASE RECORDS 213 

Treatment was conducted first by the pneumonia service of the hospital. The 
temperature fell by lysis on the 5th, 6th, and 7th days, and on July 31 the signs 
in the right chest had cleared up and the patient was turned over to the diabetic 
service. 

During the period of pneumonia the diet consisted of oranges and egg-nogs 
with whisky and cream, the caloric intake being about 1400 to 1600, as shown 
in the graphic chart. Glycosuria and ketonuria remained heavy during this 
time as indicated, but there were no symptoms threatening coma. 

Diabetic treatment was begun on Aug. 1 with fasting, with addition of whisky 
because of the convalescent condition. She thus received about 600 calories of 
alcohol daUy until Aug. 7 to 8. She was a very unwilling patient during this 
time, having been content to stay in the hospital during the pneumonia, but now 
that she felt well, she was determined to go home to her babies. She had never 
heard of diabetes and was accordingly unwilling to be treated. Her husband was 
'of equally ignorant type, but fortunately he and certain relatives had seen a 
few deaths from diabetes and comprehended the necessity of dietetic treatment. 
Accordingly she consented to remain until completion of treatment. On Aug. 
8, green vegetables were added to the whisky and gradually increased until on 
Aug. 14 they represented 80 gm. carbohydrate. The next day one egg was 
given, Aug. 17 two eggs, Aug. 18 three eggs, Aug. 19 four eggs, and the next 
■day 100 gm. fish were added. A ration was thus gradually buUt up amount- 
ing to some 1400 to 1700 calories, with 100 gm. carbohydrate and almost the 
same quantity of protein. This seemed to be an adequate but not excessive 
diet for her body weight of 54 kg., and it was tolerated without glycosuria 
or ketonuria. She received several days' instruction in the diet kitchen in the 
preparation of her food. She was not required to weigh it, but was ordered to 
take the same kinds and quantities at home as she had been receiving in the 
hospital. 

Acidosis.— A small point is noteworthy regarding the effect of alcohol. On 
fasting with whisky the ferric chloride reaction became absent on Aug. 3, and 
the glycosuria the next day. With continuance of 600 calories of alcohol daily, 
the ferric chloride reaction reappeared on Aug. 6. 600 calories of alcohol there- 
fore did not suffice to keep it absent. It cleared up on Aug. 13 in consequence 
of the addition of green vegetables to the whisky, about 50 gm. carbohydrate in 
this form sufficing for this result. 

Subsequent History. — ^After dismissal on July 31, nothing more was heard from 
the patient until Nov. 25, 1914, when she called at the hospital by request, bring- 
ing a specimen of normal urine and reporting that she had followed her diet faith- 
fully and that daily urine tests had been uniformly negative. Circumstances pre- 
vented testing the carbohydrate tolerance at that time. 

Nothing more was heard from her until she was finally located by the 
visiting nurse and called at the hospital by request on July 5, 1917. The urine 
:showed heavy sugar and negative ferric chloride reactions. The patient claimed 



214 CHAPTER in 

to feel entirely weU but looked pale and run down. She admitted that she had 
abandoned diet shortly after her previous report and since then had eaten starches^ 
sugars, and the regular family diet without restriction. She was advised to 
reenter the hospital and resume treatment, but refused on the ground that her 
children required her presence at home. 

Remarks. — ^The case is chiefly noteworthy from having been first discovered 
during an acute infection. Presumably diabetes had been present without notice- 
able symptoms before this time. It was evidently aggravated as usual by the 
infection. The case is essentially mild and readily controllable by treatment, but 
the patient's ignorance and neglect are responsible for continuance of active 
symptoms, which may be expected to bring serious trouble within a few years. 

CASE NO. 7. 

Female, married, age 36 yxs. American; clothing saleswoman. Admitted 
July 23, 1914. 

Family History. — Father died at 52 of heart trouble. Mother alive and 
healthy. All grandparents lived to old age. Five brothers and two sisters of 
patient alive and well. No diabetes or other family disease known. 

Past History. — ^Healthy life, but obesity from childhood. Only sickness scar- 
let fever. At the age of 15 patient weighed 135 pounds; before onset of present 
trouble, her weight was 168 pounds. At 18 she began work as a clothing sales- 
woman; married at 33 but continued work. No children; one miscarriage. Un- 
happy married life ending in separation. Habits said to be regular, alcohol de- 
nied. Patient was a light eater all her life and also indulged very little in candy 
or sweet dishes. Since onset of diabetes, for thirst and to stimulate strength, 
she has taken coffee to excess, at least 20 cups a day, 1 pound of cofiee every 2 
days. Nervous since onset of diabetes but not before. 

Present Illness. — Symptoms began last Dec. with pruritus vulvae. A physician 
made an examination and prescribed a local application without testing urine. 
She and her friends noticed rapid loss of weight, and she applied at the Board of 
Health for examination for tuberculosis, which was found absent. She then 
went to a medical school clinic, where the physician in charge diagnosed diabetes 
and merely gave her a list of things to eat and to avoid. During 4 months' at- 
tendance at the clinic no benefit was received, and pruritus vulvae and loss of 
weight continued. Since Mar. there has been constant pain in calves of legs, 
described as like toothache. Within the past few weeks she has had six styes 
on the left eye, which healed uneventfully. Much of her hair has fallen out. 
There is polydipsia and polyTiria but no pol3T)hagia. 

Physical Examination. — ^Nutrition still medium, though superficial tissues 
show flabbiness and wasting. Nervous facies and behavior. Posterior cervical 
glands slightly enlarged. Vagina and surroimding parts show superficial in- 
flammation. Uterus retroflexed retroverted. Examination otherwise negative. 
Wassermann reaction negative. 



CASE RECORDS 215 

Treatment. — For the first 3 days, the patient was allowed an observation diet 
Tunning as high as 115 gm. protein, 80 gm. carbohydrate, and 2000 calories. On 
this her highest sugar excretion was 63 gm. The ferric chloride reaction, whicL 
was slight on admission, became heavy on this diet, indicating that the former 
diet had included more carbohydrate. 2 days of absolute fasting were then im- 
posed. The glycosuria ceased but the ferric chloride reaction remained heavy. 
The next day 100 gm. lettuce and 100 gm. cucumber were allowed. Green vege- 
tables were increased daUy without other food untU 33 gm. carbohydrate were 
;given in this form on July 30. The ferric chloride diminished to a shght reac- 
tion, but glycosuria appeared. A fast-day with 35 gm. alcohol was then given, 
and as glycosuria immediately ceased, 27 gm. carbohydrate in the form of green 
vegetables were given the next day for the sake of acidosis. Glycosuria ap- 
peared, but the carbohydrate was continued for 2 days. Then Aug. 3 was a fast- 
•day with 70 gm. alcohol. On Aug. 4, 12 gm. carbohydrate were given as green 
vegetables, and on Aug. 5, 17 gm. The ferric chloride reaction had been di- 
minishing and was now absent. Although glycosuria remained absent, Aug. 6 
and 7 were fast-days with respectively 65 and 87 gm. alcohol. A slight ferric 
•chloride reaction returned. On Aug. 8, 90 gm. alcohol and 5.8 gm. carbohydrate 
(in green vegetables) were given. On Aug. 9, the alcohol was increased to 120 
gm. and the carbohydrate to 16 gm.; Aug. 10, alcohol 105 gm., carbohydrate 17 
gm.; Aug. 11, alcohol 90 gm., carbohydrate 22 gm. The alcohol was then dimin- 
ished to, 75 gm. and this program was continued to Aug. 16. The ferric chloride 
reaction had been well marked under the large doses of alcohol at the beginning 
of this period, but gradually diminished with the introduction of carbohydrate 
untU it became negative. On Aug. 17 one egg was added, on Aug. 20 a second egg. 
A slow increase of diet was continued, until on Aug. 27 it included four eggs, 200 
gm. meat, and green vegetables representing 41 gm. carbohydrate. Both glyco- 
suria and ketonuria were now continuously absent, the exclusion of fat having 
been the principal means by which this end was attained. Fat was then gradu- 
ally introduced, finally making a diet of about 100 gm. protein, 60 gm. carbohy- 
drate, and 2100 calories. Slight glycosuria resulted and the diet was therefore 
•diminished to 80 gm. protein and 1700 calories. 

The patient began to keep irregular hours on visits outside the hospital and 
was absent one whole night, returning with glycosuria. On Sept. 28 she went 
out and failed to return. She reappeared on Dec. 7 showing 3.3 per cent glyco- 
suria, which easily cleared up. She visited friends on Christmas and did not 
■return for 2 days. Therefore on Dec. 27 she was dismissed for this conduct, and 
no further tracing of her case was attempted. ' The impression was received that 
the patient was a drug addict or an occasional alcoholic, and that her behavior 
was thus explained, but no real proof of this supposition was obtained. 

Acidosis. — ^The only noteworthy feature is the fact that doses of alcohol from 
75 to 120 gm. failed to clear up the ferric chloride reaction or prevent its reap- 
pearance. The efficient means of stopping the persistent acidosis was found in 



216 CHAPTER III 

continued undernutrition and carbohydrate up to the limit of tolerance, with- 
abstinence from fat. 

Remarks. — The initial treatment consisted in continuous undernutrition with 
as much carbohydrate as possible. After both glycosuria and ketonuria were 
thoroughly controlled, the diet was built up by the gradual addition of first pro- 
tein and then fat. The weight at entrance was 52.8 kg. The lowest weight re- 
sulting from the undernutrition was 47.9 kg. on Aug. 19. Thereafter it gradu- 
ally rose, and at the time of her first leaving on Sept. 28 the patient weighed 50 
kg., which was a satisfactory state of nutrition for both comfort and strength. 
The case illustrates the treatment of diabetes of moderate intensity with the aid of 
only the simplest laboratory tests. The outcome was satisfactory except that 
the psychic instability of the patient precluded continuing treatment. 

CASE NO. 8. 

Male, married, age 29 yrs. American; printer. Admitted July 28, 1914. 

Family History. — Father and mother are alive and well. Mother had a goiter 
removed at age of 40 for cosmetic reasons; there were no symptoms. Grand- 
parents all healthy. Patient is the oldest of six children. No diabetes or other 
family diseases. 

Past History. — Healthy life. Measles, mumps, and chicken-pox in childhood. 
Always took cold easily; never had sore throat. Slight pleurisy 4 years ago; irk 
bed only 1 day. Regular life; no excesses Never nervous. Married 1 year ago; 
wife well, never pregnant. 

Present Illness. — In June, 1913, immediately upon return from honeymoon^ 
patient noticed abnormal thirst and dryness in mouth. Physician immediately 
diagnosed diabetes but merely prescribed a diet list, and condition rapidly grew 
worse. Patient was then referred to a New York physician who ordered a diet of 
nothing but ham and lettuce. He lived strictly on this diet for 6 weeks, eating 
as much as 5 or 6 pounds of ham a day. Sugar diminished but did not disappear. 
Other treatments were tried with a steady downward progress. He then con- 
sulted a New York specialist, who placed him on strict diet with one " green day"" 
each week, and three or four teaspoonfuls of sodium bicarbonate daily. The- 
urine was never sugar-free, and the loss of weight and strength became worse^ 
On July 25, 1914, patient entered a New York hospital, where a D : N ratio of 
3 : 1 was demonstrated on carbohydrate-free diet. Coma threatened on this diet^ 
but the addition of a slice of bread seemed to make him worse. He was then- 
transferred to this hospital in critical condition. 

Physical Examination. — An emaciated man appearing very weak. Face thin, 
and nervous. Skin dry. Acetone odor. Drowsiness and increased respiration 
very evident. Knee jerks absent. Physical examination otherwise negative. 

Treatment. — For the first 4 and a fraction days in hospital, the patient was 
placed on an observation diet as nearly carbohydrate-free as convenient, thrice 
cooking of vegetables having not yet been adopted. This diet, which represented 



CASE RECORDS 217 

77 to 135 gm. protein, 6 to 12 gm. carbohydrate, and 2800 to 3300 calories, was 
all the patient could eat. He showed the usual inability to gain weight or strength 
on full feeding, and clinical evidences of acidosis increased. 20 gm. sodium bicar- 
bonate and 20 gm. calcium carbonate were given daily. By Aug. 2 there was in- 
cipient coma with nausea, continuous dozing which was promptly resumed when- 
ever patient was roused, hyperpnea, malaise, and weakness. Fasting was there- 
fore begun from necessity. Whisky was given in 10 cc. doses hourly, amounting 
to about 100 gm. alcohol on the various fast-days. Calcium carbonate 20 gm. 
and sodium bicarbonate 30 gm. were given on Aug. 2. On Aug. 3 the bicarbon- 
ate was increased to 40 gm., on Aug. 4 it was diminished to 20 gm., and on Aug. 5 
all alkali was stopped. Clinically, meanwhile, the condition seemed to grow worse 
during the first 24 hours of fasting; the sleep was noticeably deeper. Improve- 
ment on the following day was marked and all the threatening symptoms cleared 
up rather suddenly. Sugar-freedom resulted on Aug. S, the 4th day of fasting, 
although the D : N ratio had been 3 : 1 on the feeding days. Because of the 
marked weakness, whisky was continued in doses just short of producing intoxi- 
cation, and green vegetables were gradually added, beginning Aug. 7 with 100 gm. 
each of lettuce and cucumbers. On Aug. 10 the quantity of carbohydrate in this, 
form amounted to 38. S gm., and by reason of 240 cc. whisky, the total calories for 
this day were 1073. TherewasadayofwhiskyaloneonAug.il. The program 
of alcohol and green vegetables was continued to clear up acidosis thoroughly, 
and 40 to 50 gm. carbohydrate were now assimilated daily without glycosuria. 
The ferric chloride reaction was abolished, but the patient was ravenously hungry 
and seriously weak. Accordingly, on Aug. 23 the carbohydrate was stopped, and 
the diet consisted of 4 eggs, 100 gm. butter, and 135 gm. alcohol. The eggs were 
then increased and the alcohol diminished daily, until on Aug. 27 the diet was 60 
gm. protein, 37.5 gm. alcohol, and 1660 calories. Aug. 28 was a "green day" of 
nothing but alcohol and green vegetables with 55 gm. carbohydrate. This sort of 
program continued until Sept. 11. As usual, no benefit to weight or strength re- 
sulted from the attempt to feed to the limit. Accordingly, on Sept. 12 a lower 
diet was begun, carbohydrate-free, with 80 gm. protein and 1300 calories, the alco- 
hol being at the time diminished to 20 gm. daily. For the weight of about 35 
kg. this meant less than 30 calories per kg. daily, and this was diminished still 
further by the fast-days every 1 or 2 weeks. Exercise would presumably have 
been beneficial, but the tradition was followed of keeping a patient with severe 
diabetes as quiet as possible. Therefore he was weak and cold and spent most 
of his time in a chair close to the radiator, clad in heavy clothing and double 
underwear. Nevertheless, the condition at certain times began to appear rather 
promising, since the sugar and ferric chloride reactions were frequently both nega- 
tive. A difference from the average case soon began to be noted, in that sugar 
kept unaccountably reappearing and the tolerance seemed to be perceptibly fall- 
ing under conditions when it should have risen or at least remained stationary. 
With the progress of time it became more evident that something unusual was 



218 CHAPTER ni 

breaking the patient down. Dr. Joslin chanced to see the patient on a visit and 
suggested the presence of tuberculosis, but physical signs and sputum examina- 
tions remained negative. Dec. 6 to Jan. 1, pancreas and duodenal feeding were 
attempted without benefit, as described elsewhere (Chapter IV). Thereafter 
the attempt at radical treatment of the diabetes was abandoned, and the patient 
was allowed at times to eat his fill of a selected diet. Although this diet amounted 
sometimes to 60 or 70 calories per kg., there was the usual absence of benefit 
to weight or strength, and the attempt to overfeed was doubtless a mistake. 
Certain days of lower diet and occasional fast-days were necessarily inserted be- 
cause the increasing acidosis sometimes threatened coma. On Jan. 9 he was 
transferred to the metabolism ward of the Russell Sage Institute of Pathology at 
BeUevue Hospital for calorimetric studies by Dr. Eugene DuBois.' He returned 
to this hospital on Jan. 15. The diet of 2000 calories or over during most of 
Jan. failed to prevent further loss of both strength and weight . Both the weakness 
and the rapidly falling weight were probably associated with the seriously increas- 
ing acidosis. The steep elevations in weight shown in the graphic chart at times 
in this same period represented marked edema due to sodium bicarbonate in doses 
up to 80 gm. daily. Nevertheless on Feb. 1 the point had been reached where a 
choice was necessary between fasting and immediate death in coma. A 6 day 
fast with whisky was accordingly imposed, which stopped the glycosuria and 
cleared up the threatening symptoms, though the ferric chloride reaction was not 
made negative. A lower diet was then employed, mostly about 30 calories per 
kg., on which glycosuria remained almost continuously absent and greater comfort 
was enjoyed by reason of the absence of acidosis symptoms, though the patient 
was very weak. On Mar. 16 the patient had the symptoms of catching cold 
with fever and pain in the chest. Some dulness and crepitant rMes were now de- 
tected. On account of the aggravation of the diabetes, fasting with alcohol was 
employed on Mar. 16 and 17, but the glycosuria increased. The D : N quotient 
on Mir. 16 was 2.3, on Mar. 18 it was 4.6. As death was imminent, the attempt 
at dietary restriction was abandoned and a liberal protein-fat diet with alcohol 
was permitted. By Mar. 22 the weakness had become extreme. Though there 
was chemical evidence of intense acidosis, the patient never went into typical 
coma. Death occurred at noon on Mar. 22, 1915; the patient recognized his 
wife shortly before this, though too weak to speak. 

Acidosis. — The intense acidosis during the first days in hospital was mentioned 
above. On Aug. 1 the excretion of ammonia was 3.5 gm. and that of acetone bodies 
(expressed as ;8-oxybutyric acid) was 38.6 gm. A rapid fall was evident even in 
the first 24 hours of fasting. On Aug. 8, with 16 gm. carbohydrate in the diet, 
the excretion was still 1.1 gm. ammonia and 3.1 gm. /?-oxybutyric acid. It is 
noteworthy that the period of 20 days up to Aug. 23, with a diet composed solely 
of alcohol and green vegetables in the quantities shown, failed to clear up the 
acidosis entirely, as indicated by the excretion of 0.76 gm. ammonia nitrogen and 
0.48 gm. /S-oxybutyric acid on Aug. 22. If allowance be made for the effect of the 



CASE RECORDS 219 

40 to 50 gm. of carbohydrate, which was assimilated without glycosuria, it would 
seem that no evident antiketogenic effect, was exerted by approximately 600 
calories of alcohol in the diet daily. A specific character of the acidosis perhaps 
is recognizable in such cases, by comparison with others in which acidosis is 
absent on similar regimen. Neither carbohydrate nor alcohol, but undernutrition 
was the essential factor in controlling the acidosis at all periods of the treatment. 

With a rather high carbohydrate-free diet beginning Aug. 23 there was a 
marked rise in ammonia excretion, showing the harmful effects of the attempt to 
build up strength or weight above the tolerance. With the low diet which began 
Sept. 11 there was a gradual improvement, so that even without carbohydrate in 
the diet the ferric chloride reaction became entirely negative on Oct. 7, and no 
more than traces reappeared during the time of radical treatment. Early in 
Dec, when the attempt was begun to nourish liberally on account of the assumed 
infection, there is another marked rise in the acidosis, going higher as the attempt 
was prolonged, until on Jan. 20 the ammonia excretion reached 5.1 gm. In con- 
sequence of 2 fast-days it fell sharply, then rose to 4.62 gm. on Jan. 28 in con- 
sequence of further excessive feeding. Then on fasting and lower diet it fell 
and remained at a much lower level until near the end, analyses in the last few 
days of life being lacking because of loss of some urine. 

Beginning Jan. 25, the carbon dioxide capacity of the plasma was also deter- 
mined. It is seen that although the body weight at that time was rising in con- 
sequence of edema from heavy bicarbonate dosage, the blood alkalinity fell 
sharply to a dangerously low level. With the fasting and alcohol beginning 
Feb. 1 it rose easily within normal limits, then ranged slightly below and slightly 
above the lower normal level for most of the remaining time, but dropped sharply 
almost to the coma level just before the fatal end. 

A statement of the alkali dosage is necessary for proper interpretation of the 
ammonia and COj curves. After the stopping of alkali on Aug. 5 as above men- 
tioned, no more was given until Aug. 28. From Aug. 28 to Dec. 18 inclusive, the 
patient received daily 2 gm. each of sodium bicarbonate, calcium carbonate, and 
magnesium oxide, and 1 gm. potassium bicarbonate. These were given in the 
attempt to assure against a deficit or improper balance of any or all of these 
bases, as well as to neutralize acids. Similar mixtures have been used in a few 
other cases. The points in mind have been the reported wasting of bones and ex- 
cretion of bone salts in diabetes, and also the vague idea sometimes suggested that 
a disturbance of the balance of salts or metals is at the bottom of diabetes. No 
effect of such mixtures upon the tolerance or general condition, and no advantage 
over the use of sodium bicarbonate alone, have been perceptible in any of the 
cases. 

On Dec. 19, 6 gm. sodium bicarbonate were given, and 2 gm. on Dec. 20. 
The ammonia excretion following the huge diet of Dec. 30 was less than it other- 
wise would-have been, because of the giving of 6 gm. sodium bicarbonate on Dec. 
30, and 15 gm. sodium bicarbonate and 30 gm. calcium carbonate on Dec. 31. 



CASE RECORDS 221 

Present Illness. — 1 year ago patient consulted a physician for a severe cough 
which had lasted about 2 weeks, and also for a slight injury to his right knee 
due to a fall. He was told that he had "lung trouble" and was sent to the 
country. Here he began taking a larger diet than that to which he was accus- 
tomed, and especially a great deal of cereals and starchy foods. In about 2 
weeks he began to notice polyuria and polydipsia. A physician then diagnosed 
diabetes. A list of carbohydrate-free foods, also " Metchnikoff 's tablets" were 
prescribed. For the past 9 months he has been under treatment at one of the 
best New York clinics on practically carbohydrate-free diet. The severer symp- 
toms date back 4 or S months, during which time he has lost 25 pounds in weight, 
has grown much weaker, and his cough has become worse. Constipation and 
abdominal cramps have been jnarked, with nausea and sometimes vomiting. 
There is a chronic cough, mostly at night, with expectoration of white mucus 
without blood. There was blood in the sputum on one occasion. He now 
drinks 20 to 30 glasses of water daily and passes as much as 8 quarts of urine. 
Polyphagia present. "•• 

Physical Examination. — ^Young man with nervous look, moderate emaciation, 
and general appearance of weakness. Eyes unduly bright, face flushed, skin in 
good condition. Some pyorrhea, and a few decayed teeth. Throat red, tonsils 
not visibly enlarged, cervical glands not palpable. A few subcrepitant riles in 
both apices posteriorly, and expiratory murmur slightly prolonged; lung sounds 
otherwise normal. Organs otherwise negative. Knee jerks absent. Blood 
pressure 80 systolic, 60 diastolic. 

Treatment. — The patient was placed upon an observation diet of protein, fat, 
and green vegetables for 4 days, as shown in the graphic chart. Glycosuria was 
as high as 98 gm. on Oct. 11, but the excretion of acetone bodies was not above 
1.4 gm. of /3-oxybutyric acid. Fasting with whisky was begun on Oct. 12, and 
the urine became sugar-free on Oct. 15. Nevertheless, as the patient was well 
able to endure fasting, green vegetables were not begun untU Oct. 18, when 6 
gm. carbohydrate were given in this form, increased to 15 gm. on the next day, 
30 gm. on the next, and 54 gm. on the next. Sugar was present in traces on the 
last 2 days (Oct. 20 and 21), therefore 1 more fast-day with alcohol was given on 
Oct. 22. On Oct. 23 the diet consisted of one egg, 30 gm. alcohol, and 600 gm. 
thrice cooked vegetables. The next day was similar, with two eggs and substi- 
tution of 20 gm. butter for the alcohol. Three eggs were given on Oct. 25, and 
four on Oct. 26, and then fat was gradually introduced in the form of butter and 
bacon. A little steak was added on Oct. 30. The highest diets of this period, 
Oct. 29 to Nov. 1, were only 40 to 60 gm. protein and some 1200 to 1400 calories. 
But the traces of sugar and ferric chloride reactions made a fast-day with alcohol 
advisable on Nov. 2. A higher diet was then attempted, up to 2700 calories on 
Nov. 12, with 17 gm. carbohydrate and 99 gm. protein. The rise in glycosuria 
was controlled by 1 fast-day with whisky on Nov. 16 and 2 complete fast-days 
on Nov. 30 and Dec. 1. Protein-fat diets were then employed during most of 



222 CHAPTER ni 

Dec. and Jan., the short high calory periods being atoned for by other days of 
fasting or very low diet. The carbohydrate feeding shown in the graphic chart 
for the latter part of Jan. represents caramel, which was tolerated with very little 
glycosuria. It was evident from experience that the patient's carbohydrate 
tolerance was practically nil, and symptoms returned with any attempt at protein- 
fat overfeedmg. Therefore, in Feb. he was placed on a diet of about SO gm. pro- 
tein and ISOO calories, which, if the body weight be set at SO kg., would be 1 gm. 
protein and 30 calories per kg. A fast-day once a week served to reduce this by 
i, making it equivalent to ? gm. protein and 26 calories per kg. Exercise had 
not been adopted for such cases at that time, and this patient was kept mostly 
at rest. He pronounced this diet adequate for his appetite, and was dismissed 
on Feb. 17, free from glycosuria and acidosis and, in condition for taking up some 
light occupation. 

Subsequent History. — After several weeks experience with the diet prescribed 
at discharge, the patient had professed his full ability and willingness to live 
on it, and was expected to go to some nearby place in the country and report 
frequently concerning his progress. No reports were received. It was learned 
that he had told another patient in the ward that he was not satisfied to be re- 
lieved by diet. He showed an advertisement of a proprietary remedy for diabetes 
and announced his purpose to seek a complete cure. Instead of keeping his 
promise to the hospital, he went immediately upon departure to a southern 
state. He died in Mississippi on Apr. 17, exactly 2 months after discharge. 
This information was received from a life insurance official, who was unable to 
give any particulars concerning the death. 

Acidosis. — The slightness of ketonuria at admission is presumably to the 
credit of the treatment given the patient at the clinic in the previous months. 
It was easily cleared up by the routine measures. The acetone body excretion 
remained low notwithstanding the high diets in Nov., but the ammonia rose 
to apfftoximately 1 gm. on two occasions. It fell after the fast-day with whisky 
on Nov. 16, but the fall was particularly sharp in the 2 days of plain fasting, 
Nov. 30 to Dec. 1. Acidosis was easily controlled during the hospital stay. 
There was no doubt of the inherent severity of the case, however, and the prob- 
able cause for death 2 months after leaving hospital symptom-free would 
undoubtedly be coma. 

Blood Sugar. Renal Function. — The few analyses from Oct. 11 to Nov. 2 indi- 
cated that the blood sugar was rather easily brought to normal. Traces of gly- 
cosuria appeared with a lower blood sugar level than usual for diabetic patients, 
and the findings suggested that the kidney was rather easily permeable. This 
is the more interesting in view of the fact that small quantities of albumin and 
casts were present in the urine at some times. This patient was also one of 
those who, from renal deficiency or unknown cause, are subject to marked 
edema under treatment. The sharp rise in weight on fasting and low diet, up 
to 56.2 kg. on Nov. 1, was an example of marked edema. Other peaks in the 



CASE EECORBS 223 

weight curve likewise are explainable as edema, sometimes not visible, but in the 
marked instances plainly evident in face and extremities, with pitting about the 
ankles. The rapid clearing up of edema with sharp fall in weight as shown at 
various points on the chart was regularly accomplished by salt-free diet. 

Remarks. — This patient was neurotic and secretive. Most of his difficulties 
in the hospital were neurasthenic, and the attempts to please him were responsible 
for most of the irregularities and excesses of the diet. He was admitted with 
a particular view to the suspicion of tuberculosis. The cough gradually cleared 
up during the diabetic treatment. In Jan. he had a 10 day attack of bron- 
chitis. Examinations for tubercle bacilli on 6 days of this attack as well as on 
other occasions during his hospital stay were uniformly negative. He was kept 
in the fresh air most of the time and at dismissal was continuously free from 
cough or any perceptible signs in the chest. The diagnosis of the pulmonary 
condition is therefore uncertain. 

The entire lack of ability to take carbohydrate without glycosuria on a diet 
of less than 30 calories per kg. is one index of the severity of the case. Theoreti- 
cally, some degree of tolerance should have been built up by more radical under- 
nutrition, but the patient was not psychically suitable for thorough measures. 

The treatment cannot be considered ideal in view of the dietary irregularities 
and excesses. It represents undernutrition to the extent of reducing the body 
weight from 53.6 kg. on admission to 47.6 kg. on discharge; i.e., a loss of 6 kg. 
As a result the patient felt stronger and more comfortable, and was free not only 
from the urinary signs of diabetes but also from his former subjective symptoms. 
The marked neurasthenia remained. The outcome is satisfactory to the extent 
that the patient was kept in a tolerable condition for S| months in hospital and 
was symptom-free at the close, while the actual severity of his condition was 
demonstrated by death after 2 months of unregulated diet following discharge. 

CASE NO. 10. 

Male, unmarried, age 17 yrs. Irish American; plumber. Admitted Nov. 7, 
1914. 

Family History. — Grandparents lived to old age. Parents living and well. 
One brother died in infancy; one brother and three sisters living and well. No 
diabetes or other disease known in family. 

Past History. — Healthy, vigorous life. Measles and whooping-cough in child- 
hood. No other infections; no venereal disease, alcohol, or tobacco. Has 
worked hard as plumber's helper since stopping school at 14, but he was strong 
and the work was no strain on him. Always a heavy eater; partiailarly candy, 
ice cream, pastry, and everything sweet taken in large quantities. Normal 
weight 133 pounds. 

Present Illness. — Last Jan. or Feb. the patient began to drink two gallons of 
water per day and pass urine correspondingly. He felt well at this time and was 



CASE RECORDS 225 

1000 calories was made on Dec. 29. Jan. 5 was a complete fast-day, Jan. 26 an- 
other. Generally reduced diet was used instead of fast-days because of the pa- 
tient's weakness. He gained strength very markedly during the course of treat- 
ment and began to look and act almost like a well boy. Exercise was employed 
with apparently great benefit, especially as he was naturally strong and muscular. 
He walked many miles daily, went skating on the ice, and undertook other 
activities. 

Toward the close of Jan. he and his parents considered that a cure had been 
achieved and that he was ready to go to work. As long as he felt ill he was an 
ideal patient. At this time, feeling well, he began to rebel at diet and all other 
hospital rules. The glycosuria and ketonuria during and just preceding the 
month of Feb. are attributable not to the prescribed diet, but to violations on the 
part of the patient. It became necessary to discharge him on Feb. 8, and he was 
informed that in view of his conduct this hospital could have no further connec- 
tion with his case. It was learned that he followed no regular diet thereafter, and 
died Mar. 9 with the usual acidosis symptoms. 

Acidosis. — The only alkali given was 10 gm. sodium bicarbonate on Nov. 11. 
In the absence of alkali treatment the excretion of acetone bodies was relatively 
low, reaching only 13.2 gm. of /S-oxybutyric acid on Nov. 10. For the same 
reason the ammonia excretion was high in comparison, being 3.4 gm. on Nov. 
10, 4.75 on Nov. 11, and 4.46 on Nov. 12. It is evident that fasting with alcohol 
did not immediately bring about a low ammonia, but beginning Nov. 12 the 
steepest fall occurred, down to 1 .5 gm. on Nov. IS, and 0.42 gm. on Nov. 20. The 
clinical symptoms cleared up much more strikingly than the ammonia. 

On the too abundant carbohydrate-free diet of Dec, the ammonia never fell to 
a normal level. It seemed to rise quite markedly after stopping alcohol on Dec. 
16, so that on Dec. 22 and 26 it was slightly above the level of Nov. 14 (2.18 gm.). 
Dec. 27, with a diet solely of whisky representing 85 gm. alcohol, brought a strik- 
ing drop in the ammonia, and on the lower diet following this date the ammonia 
never returned to the height of this peak, but also did not fall to normal. It 
could presumably have been brought down to normal by the use of alkali, but the 
advisability of alkali for this purpose under the circumstances is open to question. 
In this same period the ferric chloride reaction was entirely negative. Alkali 
would presumably have made it positive and increased the excretion of total 
acetone bodies. The desirability of this change is also an unknown matter. The 
real trouble was an unsuitable diet. 

Blood Sugar. — The accuracy of the single determination showing an unexpect- 
edly low blood sugar on Nov. 13 is doubtful. While irregularities are possible, it 
seems more probable that the blood sugar remained close to 0.25 per cent until 
about the close of the fast and then it fell to below 0.15 per cent. The occasional 
analyses up to Dec. 15 showed a tendency to remain within normal limits. Fur- 
ther analyses were not possible at the time. More attention should have been 
paid to this point. In correspondence with the improvement otherwise, it would 



226 CHAPTER in 

seem that the case was still at a stage when normal blood sugar values were rather 
easily attainable, and such should have been insisted upon. 

Remarks. — The earlier part of the treatment was well carried out, and the 
patient, threatened with coma, was rapidly freed from ketonuria, glycosuria, and 
hyperglycemia. This was still at an early period of experience with this method; 
it had not yet been learned that apparent restoration of tolerance is not to be 
trusted too far, and that weakened function does not so rapidly recover to this 
extent, but that it must be continuously spared by prolonged undernutrition. 
Therefore, a carbohydrate-free diet was built up too fast and too high. Even in 
the absence of laboratory danger signs, it is now known that such a procedure 
inevitably brings disaster later. The lower diet of early Jan. was more rational. 
But in general, instead of trying to make the patient feel too well and build him 
up too rapidly, a more stringent limitation of both diet and weight should have 
been insisted upon. The patient was received weighing 41.6 kg. After a sharp 
initial drop to 39 kg. in the early days of fasting, the weight remained stationary, 
then rose sharply as a result of water retention. Even with the weight of 45.6 
kg. on Nov. 28 he did not appear edematous. His tissues had evidently been 
dried before and retained water subsequently, so that he looked and felt better. 
The water thus stored on undernutrition was then driven out by increase of the 
carbohydrate-free diet, probably especially by the increase of fat, so that by 
Dec. 15 weight had fallen to the same level as at entrance. Nevertheless, the 
period from Nov. 28 to Dec. 15 must be regarded as one of actual gain of body 
substance. There was some perceptible edema when the weight rose above 47 
or 48 kg., as on Dec. 22 and Jan. 4. The patient was discharged weighing 45 kg., 
and at least part of the gain over the entrance weight may be regarded as actual 
increase of body tissue. This gain should be considered as harmful not only in- 
directly, owing to the fact that the patient became too confident from feeling too 
well, but also directly, inasmuch as tolerance ought to have been built up in- 
stead of weight. Trouble would have resulted later from this condition even if 
the patient had remained faithful, and it would have been necessary to make a 
radical restriction of his diet. Also the therapeutic possibilities are never so good 
after several months of imperfect treatment as at the outset. The cause of the 
final disaster was, however, the deep ignorance and lack of education of the 
patient and his entire family, who had no conception of the nature of the disease 
and were deaf to all advice as soon as the patient felt fairly well. Under such 
circumstances a successful outcome was precluded. The favorable side of the 
case is that such a degree of well-being and freedom from symptoms was attained 
during the 3 months in hospital, while the severity of the case was demonstrated 
by the death in comal month after breaking diet. 



CASE RECORDS 227 

CASE NO. 11. 

Female, married, age 55 yrs. Austrian; housewife. Admitted Nov. 9, 1914. 

Family History. — Father died at 55, cause unknown. Mother died at 70. 
Three brothers and three sisters of patient were healthy; one of them died at 65. 
Family are obese. No diabetes or other family disease known. 

Past History. — Patient has been strong and weU, though obese. As a young 
woman she weighed over 200 pounds, more recently she has considered 183 pounds 
her regular weight. No infections, except measles at 16. No sore throats. 
She was married at 21 ; four miscarriages; nine children born alive, four of whom 
died in infancy. All of those alive are more or less obese. 

Present Illness. — 10 years ago she began to notice a bitter taste after eating, 
also constipation. 7 years ago a doctor found 7 per cent sugar in the urine, and 
by dieting reduced it to 2 per cent. She had followed prescribed diets during 
these 7 years, but sugar was never below 2 or 3 per cent. She thinks she has lost 
weight chiefly in the last few weeks. She continued to do housework until last 
week, when she went into collapse, pale, exhausted, and vomiting blood. Her 
physician reported 7 per cent sugar in the urine. He prescribed a diet of noth- 
ing but green vegetables for 3 days. Vomiting then made eating impossible. 
Patient entered hospital in this condition with extreme weakness, anorexia and 
nausea, pain in chest and abdomen, hemoptysis, headache, and dyspnea. The 
blood brought up at first is described as being brighter and more abundant than 
now. 

Physical Examination. — An obese woman with appearance of prostration, face 
pale, also extremely cyanosed, cyanosis extending into neck. Moderate constant 
dyspnea, a weak frequent cough bringing up sputum either bloody throughout or 
streaked with dark blood. Slight jaundice. Lungs: resonance, passing into 
dulness at bases, especially posteriorly; breath sounds become bronchial in 
character over dull areas and are everywhere rough. Coarse, loud riles every- 
where. Heart is enlarged to 16 cm. to left of midsternal line and other signs are 
those of mitral regurgitation. Liver is easily palpable, lower border extending 
from 2 cm. below umbilicus obliquely into right flank barely above iliac crest. 
Pain and tenderness complained of over liver, also pain down left arm. Leg 
veins badly varicosed. Examination otherwise negative. 

Treatment. — The patient necessarily remained in bed and was treated by the 
cardiac service of the hospital with digipuratum for her evident heart failure. The 
temperature ranged from 37 to 37.6°, the pulse from 92 to 112. The urine was 
strongly acid, with specific gravity 1020 to 1025 and considerable albumin. The 
general clinical record is given in Table VHI. 

The patient was both weak and drowsy, and the symptoms were evidently due 
to a combination of acidosis and heart failure. She took no food on Nov. 9 and 
10, nevertheless glycosuria was heavy and weakness seemed to be critical. The 
condition had arisen on a diet limited to green vegetables, and the consequences 



CASE RECORDS 229 

Present Illness. — About 3 years ago abnormal weakness, thirst, and polyuria 
appeared. A physician found glycosuria of 7 J per cent. He ordered abstinence 
from sugar and pastry. The glycosuria thus diminished to 2 per cent and the 
patient felt fairly well, but after 8 months on the same diet the sugar rose to 5i 
per cent and weakness returned. He has been unable to work for the past 2 
years. For the past week he has been confined to bed because of weakness and 
pains in chest and back. There has been cough, especially at night for 2 months 
past. No fever and no hemoptysis now, but there was spitting of blood on three 
occasions last winter. 18 months ago small ulcers appeared on both feet and 
have slowly extended instead of healing; they are painful only when he walks. 
He is now nervous and constipated, and teeth have decayed rapidly. He has 
continued to lose weight. 

Physical Examination. — Patient stiU appears comfortably nourished, with good 
color in face. Tonsils slightly enlarged; part of left one is missing. Viscera 
no^al to examination. Blood pressure 150 systolic, 95 diastolic. A few patches 
of lichen planus on arms. Legs show small varicose veins threatening to ulcerate 
at some points. The skin is pigmented and scaly, somewhat eczematous. Sev- 
eral small superficial ulcers are present on ankles and feet. No gangrene. Strong 
pulse in dorsalis pedis arteries. 

Treatment. — Supper was given on the day of admission and then fasting imme- 
diately begun. Though glycosuria cleared up in 2 days, the patient being over 
weight was given 4 days of absolute fasting followed by 2 alcohol days, then 4 
days of green vegetables, then 3 fast-days, and then a diet of moderate undernu- 
trition. The superficial infections cleared up promptly. It is a question whether 
the trace of glycosuria on Nov. 16 on taking 220 cc. whisky was attributable to 
the alcohol. As frequently found at the outset in cases of this type, the food toler- 
ance was rather low. Early in Dec. a diet with only 10 gm. or less of carbohy- 
drate caused occasional traces of glycosuria, and in the period Dec. 17 to 25 the 
attempt to give IS to 40 gm. carbohydrate had to be abandoned because of per- 
sistent glycosuria. At the same time the total diet, if the mean body weight be 
taken as 80 kg., represented approximately 1 gm. protein and only 25 calories per kg. 
On strictly carbohydrate-free diet the patient proved able by Jan. 7 to 8 to take 
116 gm. protein and 2600 calories without glycosuria. As he had now been re- 
duced by about 11 kg., it was considered advisable in view of his age to allow a 
diet of this sort and let him have the benefit of improved living conditions in the 
Country and such exercise as he might be able to take. He was therefore dis- 
charged on Jan. 9 with this purpose in view. 

Subsequent History. — The patient reported at intervals that he was free from 
glycosuria, and occasional examinations at the hospital showed absence of sugar, 
very slight ferric chloride reaction, and a tendency to gain weight on the pre- 
scribed diet. Though he looked well he complained of continual weakness which 
made him unable to work. He was very faithful to all instructions, and when 
unable because of poverty to obtain the prescribed food he fasted altogether. 
He was readmitted to the hospital May 5 for further treatment. 



230 CHAPTER m 

Second Admission. — The weight at this admission was 82.6 kg.; i.e., about 4 
kg. less than at his former admission and about 7 kg. more than at his former 
discharge. His food tolerance appeared perceptibly higher, as he was now able 
to take a diet of some 120 gm. protein, 50 gm. carbohydrate, and 3000 calories 
without glycosuria. On account of the weekly fast-days these figures must be 
reduced by ^ to give the actual average intake. Undernutrition was shown by 
the fall in weight during stay in hospital. The weight gained outside of hospital 
was evidently due to unintentional overstepping of the prescribed quantities. Two 
determinations of the blood sugar gave values below 0.15 per cent. A fairly lib- 
eral diet was permitted with a view to overcoming the marked weakness, and 
exercise within the patient's limited capacity was also encouraged for this pur- 
pose. Shortly before his second dismissal he was made accustomed to a diet of 
about 100 gm. protein, 50 gm. carbohydrate, and 2500 calories, which repre- 
sented a reduction below his known tolerance to allow for unintentional errors. 
He was dismissed on June 29 greatly improved in all respects, and was advised 
again to take a rest in the country for general hygienic reasons. 

Subsequent History. — He reported in person on Sept. 7 with normal urine, feel- 
ing able to do moderate work. On Nov. 29 he was seen again; sugar and ferric 
chloride reactions were regularly negative and he was making his living at his 
usual work. He had gained about 2 kg. since discharge. The same condition 
has continued with steady improvement up to the present. He now feels well 
constantly and carries on his work without difficulty. His diet satisfies him and 
urine remains normal. 

Remarks. — This case is a good illustration of a numerous type — diabetes rela- 
tively mild but finally bringing the patient to a state of disability. The clearing 
up of such a condition generally proves to be neither quick nor easy. The most 
important therapeutic measure is the reduction of weight, which, however, may 
not have to be carried to the point of emaciation. The patient is benefited 
slowly. Unless he has full confidence in the physician, he is likely to abandon 
treatment because of the tedious privations of diet and the apparent lack of 
benefit. At first he sometimes even looks and feels worse than before. 

For the sake of strength, liberties were taken here in the direction of high 
feeding which would have meant disaster to a younger patient. More protein 
and less fat would doubtless have been better. With a weak patient at such an 
age, it was considered that the slight persistent ferric chloride reactions could be 
temporarily ignored. The outcome justified the procedure, since the continued 
freedom from glycosuria finally brought with it freedom also from ketonuria; but 
probably results could have been obtained still more rapidly by taking account 
of the acidosis and giving fairly Kberal protein for the sake of strength, very little 
fat, in order that the patient might burn off his own fat, and a little carbohydrate 
if possible. The salvation of this patient lay in his absolute fidelity. He occa- 
sionally imderwent serious privations on account of poverty without once being 
tempted to take forbidden food. His age is clearly a factor in the favorable out- 



CASE RECORDS 231 

come. He shows a tendency to gain tolerance with time. He is able to keep 
on a normal level of nutrition, and is not impaired in comfort or usefulness at 
present by his diabetes. 

CASE NO. 13. 

Female, age 11 yrs. American; schoolgirl. Admitted Nov. 14, 1914. 

Family History. — Paternal grandfather died of cancer. Antecedents otherwise 
healthy. Parents healthy. Five brothers and sisters of patient healthy. No 
obesity or other abnormalities. 

Past History. — Patient always well, apparently the strongest of the six children. 
Whooping-cough and measles before 5, mumps at 6, all mild without sequelae. 
Adenoids removed at 6. No sore throats. Regular life, not nervous. Candy 
and sweets taken in very limited quantity. Appetite, bowels, sleep, normal. 
Highest weight 59 pounds in 1913. 

Present Illness. — Sugar was found in urine April 21, 1914, the reason for medical 
examination being only slight languor for a very few days preceding. Weight at 
this time 57 pounds. She was placed immediately on the usual carbohydrate-free 
diet, with gluten bread and occasionally a little ordinary bread, a quart of milk 
every day, and a little oatmeal gruel. For the past 6 weeks the quantity of 
oatmeal has been increased. Butter and cream were used as liberally as possible 
and egg-nogs were given between meals. On this maximum caloric diet she steadily 
lost weight. Weight 1 week ago 52J pounds. She was given Fowler's solution 
of arsenic sometimes. Sodium bicarbonate was given to the extent of J teaspoon- 
ful three times a day for a few days several weeks ago, but was stopped because 
it seemed to upset the stomach. For 2 weeks past the increased respiration of the 
child had attracted the attention of her attendants, but she still seemed cheerful 
and alert. Hair falling out rapidly for past few weeks, ififowels constipated. 

Physical Examination. — A fairly normal looking, though thin little girl, lying 
quietly in bed with noticeable but not extreme polypnea. Cheeks are flushed 
more than normal. Teeth in good condition. Both tonsUs moderately en- 
larged. No lymph gland enlargement. Blood pressure 105 systolic, 75 diastolic. 
General dryness of skin, most marked on legs. Examination otherwise negative. 

Treatment. — The patient received a moderately restricted diet of 1000 calories 
for 1 full day in hospital (Nov. 15) when, with 46 gm. protein and 57 gm. carbo- 
hydrate in the diet, she excreted 46.8 gm. sugar. Fasting was then begun with 
about 20 cc. of whisky daUy. Glycosuria ceased after 3 days of fasting. On 
Nov. 19 green vegetables were added to the extent of 3 gm. carbohydrate, and 
4 gm. on Dec. 20 and 21. The glycosuria of Dec. 20 seemed to be 
clearly due to this quantity of carbohydrate, since violations of diet were posi- 
tively excluded. It cleared up spontaneously the next day, as this sort of glyco- 
suria often does. On Nov. 22, 40 gm. sugar-free caramel were given'' in doses of 

* 40 gm. caramel given on Dec. 29 not shown in graphic chart. 



232 CHAPTER ni 

5 to 15 gm. throughout the day. No glycosuria resulted, though the tolerance 
was so low. As the patient needed a diet to conserve strength, the food on Nov. 
23 consisted of 3 eggs and 14 gm. alcohol. Nov. 24, SO gm. steak were added. 
Nov. 25, the meat was increased to 100 gm. On the following days fat was added 
in the form of bacon and oUve oil, so that on Nov. 29 to 30 the diet was approxi- 
mately 46 gm. protein and 1100 calories, or 2 gm. protein and 50 calories per kg. 
for a weight of 22 kg. This allowance, abundant even for a child, caused glyco- 
suria. It was checked by a sharp reduction of diet. The glycosuria shown at 
intervals during the next 3 months was always slight, generally no more than 
faint traces in certain periods of the day, often indistinguishable if the tests were 
performed upon the mixed 24 hour urine, and sometimes connected with urinary 
calculi or with the .use of vegetables. 

! The condition was compUcated by the former trouble. In Dec, the patient 
complained of pain in back and bladder region, and painful urination. Later 
^loody urine was passed and some small clots. On Dec. 21, examination was 
piade by a urologist, and the next day x-ray plates were taken. Nothing posi- 
tive was found, but on subsequent days a few tiny calculi were passed. Several 
milder attacks of this character occurred subsequently, and seemed in each 
instance to aggravate slightly the tendency to glycosuria. 

The diet was carbohydrate-free in the strictest sense, inasmuch as this pa- 
tient could not tolerate thrice cooked vegetables, but showed glycosuria when 
attempts were made to use them. For example, on Jan. 23, after 2 weeks of 
complete sugar-freedom, 250 gm. thrice cooked celery were added to the diet and 
glycosuria appeared. The vegetables were stopped and the diet reduced, and the 
glycosuria ended. Then, on Jan. 25, 100 gm. each of thrice cooked celery, as- 
paragus, and Brussels sprouts were added, and on Jan. 26, 100 gm. each of the 
asparagus and Brussels sprouts without celery. The sUght glycosuria was checked 
by a fast-day with 11 gm. alcohol on Jan. 28. On Jan. 29 the attempt to use 300 
gm. thrice cooked vegetables was resumed, and it was again necessary to stop 
glycosuria by a fast-day on Feb. 1. Traces of glycosuria then reappeared when 
diet was resumed without the vegetables, indicating that some injury had been 
done, but a glance at the graphic chart will show that the patient soon was able 
to take a higher diet without glycosuria when all vegetables were omitted (e.g. 
45 gm. protein and 670 calories on Jan. 23, with vegetables, with glycosuria; 
45 gm. protein and 850 calories on Feb. 26, without vegetables, without glyco- 
suria). The abiUty to tolerate higher diets during the first half of Apr. (up to 
63 gm. protein and over 1900 calories on Apr. 17) must be attributed to a gradual 
gain in tolerance. Improvement was finally indicated by the ability to remain 
sugar-free on decidedly higher diets. 

As the home conditions were good and the parents absolutely trustworthy, 
it was considered feasible to let the patient take a vacation at this critical period 
in her treatment, for relief from the abnormal hospital environment. She was 
therefore dismissed on June 5 with the idea that she might be able to spend 
perhaps 2 or 3 weeks at home. 



CASE RECORDS 233 

Acidosis. — This was first measured by analyses of the acetone bodies and am- 
monia. At the outset, the characteristics of acidosis without alkali treatment 
were seen in the moderate ketonuria and high ammonia. Beginning Nov. IS, 
20 gm. each of sodium bicarbonate and calcium carbonate were given daUy. The 
sodium bicarbonate was stopped on Nov. 25, but the calcium carbonate continued 
until Dec. 4. The beginning of protein-fat diet on Nov. 23 caused a rise of the 
ammonia from 0.45 gm. up to 0.98 gm. notwithstanding the use of alkali. The 
stopping of sodium bicarbonate on Nov. 25 brought an immediate jump of the 
ammonia up to 1.8 gm. Seemingly the continuance of 20 gn^ calcium carbonate 
daily did not serve to prevent this high ammonia. Also as usual the bicarbonate 
apparently served to keep up the ferric chloride reaction, for this quickly became 
pale after bicarbonate was discontinued. It is seen that the ammonia gradually 
fell to a level which may probably be considered normal on protein-fat diet, also 
the ferric chloride reaction became negative, not in consequence of the use of 
carbohydrate which was formerly considered necessary to combat diabetic acidosis, 
but solely by reason of the gradual undernutrition. Determinations of the blood 
alkalinity were begun on Jan. 29 and showed a subnormal level of 47 vol. per cent. 
On Feb. 6, the level was still lower, viz. 41 per cent, and on Feb. 13 a still lower 
value of 39.5 per cent was found. The condition took care of itself without the- 
use of any alkali, and the combining power of the plasma remained at or above 50 
vol. per cent until the close of Apr. Up to this point the ammonia excretion and 
the ferric chloride reaction proved the more sensitive indicators. It wiU be noted that 
the ammonia curve touched its lowest point at practically the identical time with the 
lowest point of the weight curve, namely the middle of Feb., and the ferric 
chloride reaction was negative at the same time. With the increase of protein- 
fat diet came a gradual and practically parallel rise of the ammonia and weight 
curves; also ferric chloride reactions appeared and increased correspondingly. 
In the fasting periods, Apr. 29 to May 1 and May 16 to 18, the plasma bicarbon- 
ate gave indications of acidosis not revealed by the other tests. The ferric 
chloride reaction was not perceptibly altered, and the ammonia excretion distinctly 
fell in both fasts. The lowering of the plasma bicarbonate may serve as a delicate 
indicator under such circumstances, since it sometimes falls to a point giving 
warning of dangerous acidosis in fasting, and at this point clinical symptoms 
correspond. The degree of the fall was not dangerous here, and chnical symp- 
toms were absent. In the period May 15 to 19 inclusive, 5 gm. sodium bicarbon- 
ate were given daily with 30 cc. whisky, to test whether this combination of alkali 
and alcohol had any effect upon the fasting acidosis. The result showed only a 
slight difference as compared with the period Apr. 29 to May 1. The ferric chlor- 
ide reaction was unchanged, the ammonia was a bare trifle lower and the plasma 
bicarbonate a trifle higher, but the difference was within the range of accidental 
variation. Carbohydrate from 10 to 30 gm. in the forepart of May faUed to 
clear up the ferric chloride reaction, which also persisted through fasting, but be- 
came negative on the fast-day of May 23 and remained so until the diet was m-- 



234 CHAPTER ni 

creased on June 2. Here it is evident that simple increase of fat produced this 
reaction. 

Blood Sugar. — ^This was determined only occasionally in the period Apr. 16 to 
May 21, samples being taken in the morning before breakfast. The first two de- 
terminations were approximately 0.15 per cent. This was considered too high, 
and the period of almost 4 days of fasting (Apr. 28 to May 1 inclusive) was im- 
posed for the purpose of bringing it down. It was thus made and kept normal 
(as far as fasting values were concerned) until the increase of carbohydrate 
to 30 gm. on May 14 brought glycosuria with hyperglycemia of 0.18 per cent the 
fofllowing morning. A similar fasting period then succeeded in bringing it down 
almost to normal. The alkali given as above described during this phase did 
not serve to bring the blood sugar lower. Hyperglycemia again resulted from the 
subsequent diet containing 10 gm. carbohydrate, and this was one of the reasons 
for omitting this carbohydrate. 

Weight and Nutrition. — In the period Nov. 16 to 22 inclusive, with practically 
no nitrogen intake, there was a loss of 20.55 gm. nitrogen in the urine. In the 
first 3 months in hospital, undernutrition is indicated by the fall in weight from 
21,2 kg. on Nov. 16 to 16.8 kg. on Feb. 16, being a loss of 4.4 kg., or about one- 
fifth of the weight at entrance. The diet of this period, after the brief excess in 
Nov., was in the neighborhood of 45 gm. protein and 700 calories, or a little 
over 1 gm. protein and 35 calories per kg. of weight, but the rather frequent 
days of fasting or low diet reduced the average materially below this figure. Gain 
in weight began with the increase of diet in the latter part of Feb. In conse- 
quence, both sugar and ferric chloride reactions were present early in Mar. There- 
after the ferric chloride tests and the unduly high ammonia were the chief indi- 
cations of improper diet. 

In the early half of Apr. the ration was generally 63 gm. protein and 1700 to 
1900 calories (about 3.3 gm. protein and 90 to 100 calories per kg.) with fast- 
days somewhat reducing this average. On Apr. 19 a better balanced diet was 
instituted, consisting of 49 gm. protein, 5 gm. carbohydrate, and 1322 calories, 
increased by May 14 to 57 gm. protein, 30 gm. carbohydrate, and 1593 calories. 
Distinct glycosuria resulted at this time. After a period of fasting, a decidedly 
lower diet was given beginning May 19. Though the ability had been shown to 
tolerate 10 gm. carbohydrate during this time, it was considered safer to boil out 
carbohydrate in the diet at home. Accordingly the diet prescribed at discharge 
consisted of 68.5 gm. protein, 250 gm. thrice cooked vegetables, and 1500 to 1600 
calories (about 3.5 gm. protein and 80 calories per kg., reduced by weekly fast- 
days to about 3 gm. protein and 70 calories average). 

At discharge the weight was 19 kg.; i.e., 2.2 kg. less than at admission. The 
half year of treatment thus represented imdernutrition to this extent. There 
was no gain, and if anything a slight loss of strength, also no growth in stature. 
The child was thoroughly cheerful, and able to be about and keep herself amused 
all day. 



CASE RECORDS 235 

Subsequent History.— The progress at home was better than expected. Reports 
and samples of urine showed continued absence of both sugar and ferric chloride 
reactions. On July 1 the addition of 5 gm. carbohydrate was tolerated. On Aug. 
1 an increase to 10 gm. carbohydrate brought a trace of glycosuria. The allow- 
ance of S gm. continued to be tolerated, and the child gained also in weight and 
appearance. Oct. 3, occasional traces of sugar were reported, and on advice the 
patient returned to the hospital on Oct. IS for further treatment, having suc- 
ceeded in remaining in good condition at home for 4 months instead of the few 
weeks anticipated. 

Second Admission. — The patient returned weighing 20.8 kg.; i.e., with a gain of 
1.9 kg. over her weight at discharge and a loss of O.S kg. from her weight on first 
admission. Her appearance and actions indicated a decided gain in vigor. 
On the same carbohydrate-free diet prescribed at discharge she showed moderate 
glycosuria, marked hyperglycemia (plasma sugar 0.25 per cent), a well marked 
ferric chloride reaction, and a slightly subnormal plasma alkalinity. Accordingly 
fasting was begun on Oct. 17, and sugar-freedom resulted within the first 24 hours. 
After an additional 24 hours of fasting, a carbohydrate tolerance test with green 
vegetables was begun for the usual diagnostic and therapeutic reasons. Beginning 
as usual with 10 gm. carbohydrate on Oct. 19, an increase of 10 gm. carbohydrate 
was made daily, with the result that 60 gm. carbohydrate was established as the 
tolerance. The traces of glycosuria on Oct. 25 and 26 exemplified the false limit 
sometimes encountered in such tests, when there is a trivial excretion on a cer- 
tain intake, which disappears after this intake is continued or increased. This 
affords no comparison with the tolerance on the previous admission, because no 
test was then made with carbohydrate in the absence of other foods. In con- 
sequence of this undernutrition with carbohydrate to the point of tolerance, the 
blood sugar as determined mornings before breakfast fell to normal, the ferric 
chloride reaction became negative, and the plasma bicarbonate rose to normal. 
After a fast-day on Oct. 31 to clear up the glycosuria resulting from the carbo- 
hydrate test, a diet was begun which was better planned than on the previous 
admission; namely, 50 gm. protein, 10 gm. carbohydrate, and 1000 calories. Be- 
cause of glycosuria it was necessary on Nov. 8 to reduce the carbohydrate, and 
after Nov. 15 it was regularly 5 gm. For a body weight of 20 kg., this diet rep- 
resented 2.5 gm. protein and 50 calories per kg. The weekly fast-days reduced 
this to an average of approximately 2.14 gm. protein and 43 calories per kg. 
The general well-being was definitely improved by this lower diet and the intro- 
duction of carbohydrate, as compared with what was observed on the previous 
admission. The carbon dioxide capacity of the plasma, which had been as low 
as 45 per cent, rose to 55 per cent without the use of alkali. The blood sugar, 
which had risen with the appearance of glycosuria at the close of the carbohydrate 
test, continued unduly high, but remained below 0.2 per cent and gradually fell 
below 0.15 per cent. The patient was dismissed on Dec. 14 weighing 19.3 kg.; 
i.e., 1.5 kg. below her weight at this admission, and 0.4 kg. above her weight at 
the former discharge. 



236 CHAPTER III 

Exercise. — During the former time in hospital the chUd was kept at rest, partly 
because of weakness. This time she was given regular exercise to the limit of 
comfortable endurance. No detailed studies were made, but it was evident that 
no striking increase in tolerance was produced in such a severe case of diabetes. 
Existing glycosuria was not cleared up by exercise, also it was not possible to 
raise the carbohydrate ration higher with exercise than without. On the other 
hand, the exercise certainly did no harm; it may have had a share in the gradual 
reduction of the hyperglycertua; and it unmistakably improved the strength, well- 
being, and enjoyment of the child. The exercise was mostly in the form of ball- 
tossing, walking, roUer-skating, and other play. 

Subsequent History. — The patient remained sugar-free at home, and took up 
some school work in Feb., 1916. Increase of carbohydrate to 10 gm. was tolerated 
without glycosuria. In May she caught cold, showed traces of sugar almost con- 
stantly, and lost IJ pounds in 2 weeks by reason of the undernutrition necessary 
to keep down glycosuria. Her former tolerance returned with recovery ftom the 
cold. Glycosuria remained absent practically continuously until July, when 
persistent traces of sugar made it advisable for the patient to return to the 
hospital. 

Third Admission. — ^July 7, 1916. The weight at this admission was 20 kg.; 
i.e., 0.7 kg. more than at discharge 6i months previously. The height was 132 
cm. Under regular diet, July 7 to 10 inclusive, there were stiU marked sugar and 
ferric chloride reactions. The plasma sugar on July 11 was again 0.25 per cent, 
and a rigid period of undernutrition, including fasting and a carbohydrate test, 
was therefore instituted. The tolerance for carbohydrate was identical with 
that in the previous October. The treatment reduced the blood sugar to 0.13 
per cent, but it rose to 0.22 per cent on resumption of the previous diet. The 
weight was thereby reduced to 17.2 kg., which was lower by 4 kg. than at the 
first admission. The patient was still cheerful and active, and returned home in 
this condition. 

Subsequent History. — In Aug., on account of shght glycosuria, carbohydrate was 
omitted from the diet. The disturbance seemed to be associated with kidigestion. 
Otherwise the sugar and ferric chloride reactions remained negative. The patient 
attended school half of each day, and took automobile rides and other recreation. 
In Oct. bloody urine reappeared and two small calculi were passed. This trouble 
seemed to affect her diabetes very badly, and for this reason she reentered the 
hospital Oct. 24, 1916. 

Fourth Admission. — Weight 19.3 kg. Appearance thinner, paler, and weaker 
than previously. The change for the worse is said to date from the attack of cal- 
culi. The urine by this time was free from blood, and physical and x-ray examina- 
tions were negative. The patient was made sugar-free by 2 days of fasting, then 
given green vegetables representing S gm. carbohydrate the first day, increasing 
by 5 gm., daily up to SO gm., which was the Umit of tolerance; i.e., a loss of 10 gm. 
as compared with previous tests. She was then placed on a diet of 30 gm. pro- 



CASE EECOIOJS 237 

tein, 20 gm. carbohydrate, and 600 calories, and was encouraged to exercise 
within the hmits of her strength. A routine fast-day was given once a week. 
Because the strength remained low, this diet was changed on Nov. 23 by dimin- 
ishing the carbohydrate to 10 gm. and increasing the protein to 40 gm. For the 
same reason on Dec. 4 carbohydrate was omitted from the diet and the protein 
increased to 45 gm. The patient at this time took walks of 8 blocks without 
weariness, and was outdoors much of each day. Blaud's pills were given because 
of anemia. The patient remained in hospital until Feb. 1, 1917, when she was 
dismissed on a carbohydrate-free diet of 40 gm. protein and 700 calories, weigh- 
ing 17 kg.; i.e., 1.2 kg. less than at this admission, and 4.3 kg. less than at her 
original admission in Nov., 1914. 

Acidosis. — The ferric chloride reaction remained constantly negative. Traces 
of acetone were constantly present, as must be expected on such a diet. There 
was a daily excretion of 0.18 to 0.64 gm. ammonia nitrogen, the output being 
lower in the earUer period of lower calories with carbohydrate in the diet. Symp- 
toms of acidosis were entirely absent, and the carbon dioxide capacity of the 
plasma was 65.3 per cent at dismissal. 

Blood Sugar. — ^Hyperglycemia was continuous, in general close to the threshold 
of glycosuria as shown in the charts of former periods. The blood sugar at dis- 
missal was 0.2 per cent. 

Subsequent History. — The condition continued the same at home as in hospital, 
the patient remaining very thin but bright and active. In Mar. a "green day" 
was advised in the middle of each week to break the monotony of the diet, di- 
minish the total calories, and introduce carbohydrate. Traces of sugar appeared 
only occasionally and at first cleared up with the routine fast-days. The usual 
slow downward progress occurred under these circumstances, but owing to the 
■derangement of the hospital organization by the military emergency, the patient 
was not required to return for treatment until Oct. 10, 1917. By this time she 
had been seriously weakened by the frequent fasting necessary to control glyco- 
suria, though she was still up and about. 

Fifth Admission.— Oct. 10, 1917. Weight 16.6 kg. The patient had stood the 
trip from Massachusetts very well. One day of fasting cleared up the shght 
existing glycosuria. On the second fast-day the plasma sugar was 0.098 per cent, 
CO2 capacity 55 per cent. On the evening of the second day the fast was broken 
with 5 gm. carbohydrate in the form of a salad. The urine was continuously nega- 
tive for both ferric chloride and nitroprusside reactions, and the nitroprusside test 
of the plasma was likewise negative. Carbohydrate was increased by 5 gm. daily 
without glycosuria. Oct. 16, breakfast was taken as usual, but collapse occurred 
about 10 a. m. and death about noon, preceded by slight tetanoid convulsions. 
The urine at this time was still normal. The blood showed hemoglobin 22 per 
cent, plasma sugar 0.02 per cent, CO2 capacity 69.7 per cent. The employment 
of the carbohydrate test was a mistake, for though the child was up and about 
until the day before death, the low blood sugar on the second fast-day was a 



238 CHAPTER in 

pkin indication of exhaustion, and protein should have been fed instead of car- 
bohydrate. Nothing, however, could long have prevented the fatal termination 
under the circumstances at this time. 

Remarks.— The patient presented juvenile diabetes of great severity. Within 
about half a year she had come close to coma and had lost carbohydrate tolerance 
almost completely. It is evident that the assimilation had already fallen too low 
to support growth, owing to lack of treatment in the earlier stage. Under treat- 
ment she was then kept alive and in tolerable comfort and activity for nearly 3 
years. Two aspects of the progress may be noted. 

On the one hand, no special tendency to recovery of assimilative function has 
been manifest. During the first period of over 6 months in hospital, it is true 
that the food tolerance decidedly improved, but this result was merely the accom- 
paniment of some 2 kg. loss of weight and does not necessarily indicate any 
change in the fundamental assimilative power. At the second admission the 
weight was up almost to the original figure, but other conditions were different. 
Active diabetes was present again at this admission. The carbohydrate tolerance- 
was tested with exclusion of other foods. Thereafter carbohydrate could be in- 
cluded in the diet, but this was on a lower ration than during the first admission. 
Real improvement in assimilation would have meant that the child could grow in 
weight and stature; on the contrary, the third and fourth admissions represented 
further loss of weight. The carbohydrate tolerance in July, 1916, was the same 
as in Oct., 1915, but as the latter test was at a lower body weight, the result may 
be interpreted as actual downward progress. 

On the other hand, the record furnishes evidence against the "spontaneous" 
character of such downward progress. Hyperglycemia was almost continuous,, 
and glycosuria and ketonuria recurred rather frequently throughout the entire 3 
years. A partially depancreatized dog under similar conditions would have gone 
into hopeless diabetes much sooner. Any inherent downward tendency should 
have been perceptible in this type of case in this length of time. The slow change 
observed is abundantly explainable by the prolonged slight overstrain of the 
weakened function. 

CASE NO. 14. 

Male, married, age 51 yrs. American; optician. Admitted Nov. 16, 1914. 

Family History.— Fkthei died of typhoid at 28, mother of heart trouble and' 
dropsy at 55. Two sisters living and well. Patient has been married 23 years; 
one child dead, one living and well. Tuberculosis, cancer, syphilis, diabetes, and 
other family diseases denied. 

Past History.— Kenlthy life. Scarlet fever in childhood. Occasional sore 
throats. Gonorrhea twice. Syphilis denied by name and symptoms. In Apr., 
1914, he was confined to bed with so called dry pleurisy and had cough and 
slightly blood-tinged expectoration for 3 or 4 weeks. Constipation, slight indi- 
gestion, moderate or poor appetite. Alcohol used rather freely but not to- 
drunkenness. Moderate tobacco. 



CASE RECORDS 239 

Present Illness. — 7 years ago patient states that he strained himself lifting a 
trunk. He had pain in the back for several months, therefore had his urine 
examined and sugar was found. He claims never to have had any of the typical 
diabetic symptoms. He now complains of indefinite neuritic pains in back and 
legs. His best weight was 140 pounds 6 years ago; now 112. A few days after 
• admission the patient's wife volunteered the information that he had undertaken 
a number of different treatments for his diabetes at different times, but had never 
adhered to any prescribed diet for even a brief time. 

Physical Examination. — ^A fairly developed, poorly nourished man. Teeth 
mostly absent, little decay in those remaining, slight pyorrhea. Throat con- 
gested but tonsils not visibly enlarged. Cervical, axiUary, epitrochlear, and in- 
guinal glands slightly enlarged. Reflexes very active. Blood pressure 100 sys- 
tolic, 70 diastolic. 

Treatment. — ^After 2 days of observation on a low protein-fat diet, fasting was 
begun on Nov. 18. On Nov. 20 to 22 he received 27 to 35 gm. alcohol. This 
S day fast greatly diminished but did not quite abolish glycosuria. The ferric 
chloride reaction, which was negative on the day of admission, became strongly 
positive on the carbohydrate-free diet and on fasting. The weight fell sharply 
from 50.6 to 47.6 kg. On Nov. 23, 300 gm. thrice cooked vegetables were given 
to appease the patient, who was discontented. This program continued up to 
and including Dec. 1. As such vegetables are reckoned as having too little food 
value to count, the treatment represents 2 weeks of practically continuous fasting 
except for the alcohol mentioned. The continuance of glycosuria aroused sus- 
picion. Accordingly the patient was removed from the ward to a private room, 
and glycosuria abruptly ceased (Nov. 26). He was then returned to the ward, 
and was sufficiently impressed by his sugar-freedom that he followed diet with 
some degree of fidelity thereafter, though some of the traces of glycosuria are 
doubtless to be attributed to slight violations. A low diet was begun, and it was 
found that the tolerance was actually very low, the smallest quantity of carbo- 
hydrate bringing on glycosuria, while even on protein-fat diet traces of sugar were 
frequent, apart from any steaUng of food. The patient was discontented and 
unreliable, and the irregular shifts of diet resulted largely from attempts to please 
him. The general outcome of the treatment was to reduce his weight from the 
original 50.6 kg. to 44.8 kg., with the result that glycosuria was absent on a car- 
bohydrate-free diet of 53 gm. protein and over 2200 calories, but a well marked 
ferric chloride reaction persisted. Thorough treatment was not carried out 
because the patient had never been seriously iU and would not have endured 
rigorous measures. Accordingly he was allowed to go on Mar. 2, with his con- 
dition improved but by no means satisfactory, on a prescribed diet of about 50 
gm. protein and 1500 to 1750 calories. 

Subsequent History. — On Apr. 1, patient returned to the hospital reporting that 
he had followed diet, had remained permanently sugar-free, had gained 6 pounds, 
and was enjoying greatly improved health. His appearance conformed to the 



240 CHAPTER m 

statement, but a sample of urine showed a trace of sugar. Information from other 
quarters indicated that he had not adhered strictly to his diet. On Apr. 9, he 
again reported and his urine was found sugar-free. On May 20, he reported 
showing a slight glycosuria, and information was given by his family that he had 
departed somewhat from his diet. Since then nothing has been heard of him. 

Remarks. — ^The case illustrates diabetes of long standing, apparently doing the- 
individual little harm but bringing progressive injury in the course of years, 
and undoubtedly destined not only to impair comfort and usefulness, but also 
to shorten life. As frequently found in such cases, a normal state of the urine is 
very diflBicult to establish and maintain, and rigorous restriction of food and re- 
duction of weight for a number of months are necessary for a satisfactory re- 
sult. Such patients are often not convinced that these measures are necessary, 
especially since they feel decidedly worse during the period of rigorous restric- 
tion. FideUty brings ultimate reward in comfort and longevity. On the other 
hand, the penalty of carelessness is often slow in appearing, and accordingly the 
lesson is often learned too late. 

CASE NO. 15. 

Male, married, age 42 yrs. Scotch; bookkeeper. Admitted Nov. 16, 1914. 

Family History. — ^Entirely negative as far as can be learned from wife. 

Past History. — Healthy life. 

Present Illness. — Patient is known to have had diabetes for about 2 y^ars past, 
with practically no symptoms except some loss of weight and strength. He has 
continued at his work until the present week. He was not supposed to be seri- 
ously unwell until last evening, when a doctor was sent for hurriedly and found 
him in coma to such a degree that he could not be roused enough to recognize 
persons. The physician cleared out considerable feces by the use of cathartics 
and enemas and gave a few small doses of sodium bicarbonate by mouth. This 
morning the patient was stiU in coma, but was apparently a little more easily 
roused. 

Physical Examination. — Fairly good muscular development along with moderate 
emaciation. Routine physical examination negative. Kjiee jerks absent. The 
usual picture of coma, except that h3Tjerpnea is not striking. Respiration is 
fuU, but quiet. When forcibly roused the patient regains consciousness suffi- 
ciently to utter words in drunken meaningless fashion, but not to recognize his - 
wife or doctor. With some difficulty he can be induced to swallow medicine and 
to pass urine. 

Treatment. — ^This was the first case of actual coma received, and the orthodox 
treatment was attempted, with an intravenous infusion of 1 liter of 4 per cent 
sodium bicarbonate solution prepared without heat and sterilized by filtration 
through porcelain. The injection was apparently well borne; pulse, respiration, 
and consciousness showed no appreciable, change during the period of injection, 
which lasted about an hour. IS cc. whisky were given hourly. The patient 



CASE RECORDS 241 

was received at 5 :30 p.m. The infusion was finished at 7 p. m., and death occurred 
suddenly and without warning at 7:50 p.m. 

The following laboratory data may be noted. Heavy glycosuria and ketonuria 
both before and after bicarbonate infusion, not determined quantitatively because 
of loss of considerable urine. Blood sugar 0.316 per cent. Sodium chloride in 
serum 6.11 gm. per liter. Sodium chloride in urine 0.2 gm. per hter before in- 
fusion. The urine passed after bicarbonate infusion was pale and abundant as 
before, but contained no chlorides. 

Remarks. — Though few patients ever come out of actual coma, this man was 
one who appeared to have a fighting chance. At that time it was hoped that 
the alkali in the customary dosage would reinforce whatever benefit he might 
derive from fasting. Without the intravenous alkali he might have had a chance. 
Later experience makes it seem probable that when a patient in this condition 
receives an injection of alkali in this manner and quantity, no immediate harm 
and sometimes an apparent benefit is perceptible, but sudden death is likely to 
occur within a few hours. 

CASE NO. 16. 

Female, married, age 47 yrs. American; housewife. Admitted Nov. 17, 
1914. 

Family History. — Father died of cancer at 61. Mother had diabetes; died of 
sepsis from varicose veins in legs at 74. Brother aged 61 has mild diabetes. 
Patient's husband died 20 years ago, aged 34, of some condition resulting from 
alcoholic excess. Three chUdren; the two older living and weU; the youngest 
was mentally deficient and died last July at the age of 20, after having been 
treated from childhood for syphilis. 

Past History.— Healthy childhood. Measles and mumps when very young. 
Chlorosis before marriage. Married at 20; two children within a year of each 
other; no miscarriages. Third child, born 4 years after second, showed syphilis, 
and patient after its birth had sore on tongue and hair fell out. There was also 
a genital chancre. Symptoms cleared up after 1 month of treatment with blue 
ointment. No further symptoms or treatment. Regular habits. No excess in 
alcohol, tea, coffee, or sweets. Never nervous until recent years. Ordinary 
weight 180 pounds. 

Present Illness. — 5 years ago patient began to feel weak and lost 20 pounds in 
weight. Physician found glycosuria of 4§ per cent. She has dieted more or less 
since then, but has been sugar-free only occasionally, never more than a few 
months. Lowest weight 143 pounds last August. Menstruation stopped 6 
months ago. Especially for the past 3 weeks she has felt weak and miserable and 
been troubled with thirst, headache, pains in knees, cold feet, pruritus vulvae, 
failing vision, and loosening and falling out of teeth. 

Physical Examination. — Height 158 cm. A rather obese woman, looking 
strong but nervous. Several teeth missing; others loose. Throat normal. No 



242 CHAPTER m 

palpable lymph node enlargement. Murmur of mitral regurgitation. Area of 
cardiac dulness slightly enlarged. Arteries hardened. Blood pressure 225 
systolic, 110 diastolic. Albumin and casts in urine. Knee and Achilles jerks 
slight. . A few small copper colored scars on legs. Uterus sUghtly retroverted. 
Right Fallopian tube slightly tender. Blood shows strong Wassermann reac- 
tion. In addition to diabetes, there was a diagnosis of chronic mitral insuffi- 
ciency, chronic interstitial nephritis, latent syphilis, arteriosclerosis, and cystitis. 
Twice during hospital sojourn the patient complained of dizziness and fainted, 
and was treated for short periods with digipuratum. Syphilis was not treated 
at this time, and the effect of dietetic treatment of the diabetes was tested alone. 

Treatment. — ^As shown in graphic chart, the patient fasted Nov. 18 to 20 inclu- 
sive, receiving respectively 45 and 75 cc. whisky on the last 2 days. On Nov. 
21 she received cauliflower, celery, and asparagus to the amount of 17.5 gm. car- 
bohydrate. As the primary object was to reduce weight, 3 more days of practi- 
cal fasting (Nov. 22 to 24) followed, the only food being 800 gm. thrice cooked 
vegetables daily. On Nov. 25, one egg was added. This diet was rapidly in- 
creased to about 1100 calories on Dec. 6 and 2300 calories on Dec. 19. AU at- 
tempts to introduce even small quantities of carbohydrate led to glycosuria, and, 
as shown in graphic chart, numerous periods of low diet or fasting were employed 
to diminish the weight further. She was finally (Jan. 27 to 29) placed on a car- 
bohydrate-free diet of 66 gm. protein and 1400 calories. This, for her weight of 
54.5 kg. at that time, was about 1.2 gm. protein and 26 calories per kg. The pa- 
tient insisted that this diet with addition of 500 gm. thrice boiled vegetables satis- 
fied her appetite perfectly, and as she was very eager to be home and had received 
the necessary instruction, she was allowed to leave in this condition. All sub- 
jective symptoms had disappeared and she felt fuUy strong and well. 

^Subsequent History. — The progress continued to be favorable at home, and in 
Feb. the diet was increased by 400 calories of bacon. Sugar remained constantly 
absent and the ferric chloride diminished to a trace. It became entirely negative 
about June 1. The plasma sugar on June 1 was 0.114 per cent. The weight 
was 54.5 kg. By Oct. 5, the patient had gradually increased the quantity of food, 
the weight had risen to 59.8 kg., and the plasma sugar to 0.196 per cent, with nega- 
tive sugar and ferric chloride reactions in urine. Blood pressure 250 systolic, 160 
diastolic. She was advised to avoid gaining weight. Excellent subjective 
health and normal urine continued, and 1 year after discharge she reentered the 
hospital by request for examination and advice. 

Second Admission. — ^Jan. 31, 1916. The weight at this time was 63 kg.; namely, 
8.6 kg. above that on dismissal and 2 kg. below that at former admission. The 
urine showed negative sugar but a trace of ferric chloride reaction. Feb. 2 a fast- 
day was given, and then a carbohydrate tolerance test, begiiming with 10 gm. 
carbohydrate and increasing by 10 gm. daily vmtil by Feb. 23 to 25 the limit of 
tolerance was reached with 220 gm. carbohydrate. After a fast-day on Feb. 27 
to clear up the slight glycosuria, a diet was instituted of 90 gm. protein, 20 gm. 



CASE RECORDS 243 

carbohydrate, and 2000 calories (1.5 gm. protein and 34 calories per kg., reduced 
by weekly fast-days to about 1.3 gm. protein and 30 calories average). On this 
diet the patient was dismissed, weighing 59.5 kg. 

Acidosis. — The patient was admitted originally with chronic glycosuria and 
negative ferric chloride reaction. The result of fasting, notwithstanding 75 cc. 
whisky on Nov. 20 and 17.5 gm. carbohydrate on Nov. 21, was the development 
of a ferric chloride reaction. This persisted during most of the first stay in hos- 
pital. It could doubtless have been cleared up by repeated periods of carbohy- 
drate (without other food) to the limit of tolerance. But the tolerance at that time 
was low, and for a patient with such inherently mild diabetes at a fairly advanced 
age, it was considered sufficient to pursue a treatment of progressive undernu- 
trition, knowing that the trivial acidosis would disappear as soon as the tolerance 
was built up. This expectation was fulfilled in the period after leaving hospital. 
With rise of weight, traces of ketonuria had returned at the time of second admis- 
sion; these were readily cleared up by the carbohydrate tolerance test, and by 
increasing carbohydrate in the diet. Since then ketonuria has remained per- 
manently absent. As shown in the second graphic chart, the plasma bicarbon- 
ate was slightly below the lower normal limit; but the tendency was upward, and 
no alkali was employed. 

Blood Sugar. — ^This was easily kept at normal level by regulation of body weight. 
On this point the patient might be brought into line with the type formerly called 
"fat sensitive." It wiU be observed in the second graphic chart that hyper- 
glycemia was present on Feb. 2 after a diet of 2350 calories made up chiefly of 
fat with very little carbohydrate. This elevated blood sugar is seen to have fallen 
to normal subsequently when the carbohydrate was decidedly increased and the 
total calories diminished. Though nephritis and arteriosclerosis were present 
with hypertension, there was no tendency to a stubbornly high blood sugar. 

Subsequent History. — The patient has reported at intervals to date, feeling en- 
tirely healthy and leading a fully normal life with faithful attention to diet. 
Weight June 19, 1917, 63.6 kg. This increase of weight has been borne with&ut 
any glycosuria. The high blood pressure remains, also the albumin and casts in 
urine. Lately she has complied with advice given several times before and has 
taken a few salvarsan injections, without alteration of clinical findings. The 
cardiorenal symptoms are perceptibly increasing, and death from this cause is to 
be expected. 

Remarks. — Two possible etiologic factors are here present, one heredity, the 
other syphilis. Notwithstanding these, and even in absence of syphilitic treat- 
ment, the entire tendency under suitable dietetic treatment through nearly 3 
years of observation has been upward and not downward. This success has been 
attained by regulation of the total caloric ration and body weight. It is practi- 
cally certain that a progressive downward tendency could have been observed if 
the weight had been built up with high calory, carbohydrate-poor diet. Such a 
tendency is distinctly indicated by the findings at several times when weight was 



244 CHAPTER ni 

gained. Another interesting feature is that in Apr., 3 months after the first 
dismissal, the patient had an acute otitis media and underwent paracentesis under 
ether, but showed no sugar throughout this illness. From present indications the 
prognosis in such a case is satisfactory from the standpoint of diabetes, and life 
and comfort are apparently limited only by the other diseased conditions present. 

CASE NO. 17. 

Female, married, age 69 yrs. Russian Jew; housewife. Admitted Nov. 17) 
1914. 

Family History. — Indefinite on account of ignorance. Most of family seemingly 
lived to considerable age, and patient knows of no family diseases. Patient has 
been married 43 years. Seven children; four died in infancy, cause unknown; one 
is in a pubhc institution with diagnosis of dementia praecox; the other two are 
middle-aged and well. 

Past History. — Measles in childhood. Came to New York from Russia 26 
years ago. Hygienic surroundings bad. No diseases of consequence, except em- 
pyema with pneumonia 20 years ago. This was drained, and two subsequent 
operations were necessary before the sinus was closed a year later. She has had 
no s)rmptoms pointing to tuberculosis. She has long complained of indigestion, 
gas, and constipation. 6 years ago she underwent an operation for uterine pro- 
lapse; there was a laparotomy and removal of some sort of tumor, concerning 
which she knows nothing except that it was not cancer. 

Present Illness. — ^Time,of onset unknown, but during the past 7 years her weight 
has steadily diminished from 180 down to 108 pounds. Polyphagia never marked, 
and polydipsia noticed only in the past few days. 6 weeks ago pain began in 
the right foot with some discoloration around the great toe and heel. Local 
measures did not benefit it. A physician suspected gangrene immediately upon 
seeing it and found heavy glycosuria present. This was the first diagnosis of 
diabetes. She is now unable to walk because of pain in this foot, which is also 
painful when she remains in bed. 

Physical Examination. — Patient fairly nourished, lying in bed with quiet respira- 
tion, but with decided sweet odor of breath. Dirt and pedicuH noticeable. Nu- 
merous teeth missing or carious. No gland enlargements except in groins. A 
few bronchitic rales. Heart sKghtly enlarged. Blood pressure 215 systolic, 150 
diastoUc. Depressed scars on left thigh, pigmented scars on right shin. Swell- 
ing, reddish blue discoloration and tenderness of great toe and over and under 
first and second tarsometatarsal joints of right foot. The heel of this foot is 
painful, the skin is Hfted up and evidently has fluid under it. 

Treatment. — Patient received supper on the day of admission, consisting of 25 
gm. AkoU biscuit, 10 gm. butter, and a cup of coffee. The next day she fasted 
with 35 cc. whisky, and became sugar-free in 24 hours. The ensuing days were 
also fast-days, with whisky up to 90 cc. On Nov. 23, one egg and 300 gm. thrice 



CASE RECORDS 



245 



boiled vegetables (cauliflower and asparagus) were added. The diet was then 
rapidly increased, particularly in its fat component,, as shown in Table IX. 

It is seen that the great increase of fat intake on Nov. 29 was accompanied by 
sharp increase of both glycosuria and ferric chloride reactions. The simul- 
taneous increase of protein in the diet did not serve to prevent this increase of 
acidosis. Also it is difficult to attribute the glycosuria of 11 gm. to the increase of 
only 5 gm. protein on Nov. 29, as compared with the preceding day. Further- 
more, though this glycosuria was only 11 gm., because the high diet was composed 
chiefly of fat, the injurious after-effect is likewise characteristic of fat. For the 
entire first week in Dec. the diet was only once as high as 500 calories; Dec. 5, 6, 
and 7 were fast-days with alcohol, yet the aglycosuric condition was difficult to 
restore. Beginning Dec. 8 the attempt was made to build up a diet, beginning 
with eggs, butter, and 'thrice cooked vegetables. Whisky was never entirely 
discontinued, and in Jan. the intake represented about 65 gm. alcohol daily. 
The protein was generally 40 to 60 gm.; i.e., a httle above or below 1 gm. per kg. 

TABLE rx. 



Date. 


Diet. 


Weight. 


Urine. 


















Protein. 


Fat. 


Alcohol. 


Calories. 




Volume. 


Sugar. 


FeCb 
reaction. 


1914 


em. 


em. 


am. 




ke. 


cc. 


em. 




Nov. 27 


47 


135 


43 


1746 


50.6 


1540 


+ 


-f-l-H- 


" 28 


57 


179 


15 


2005 


51.6 


2005 


+ 


++ 


" 29 


62 


509 


15 


5096 


50.5 


1115 


11.15 


-1-4- H- 


" 30 


37 


259 


10 


2629 


51.3 


1190 


+ 


+++ 


Dec. 1 


37 


259 


15 


2664 


51.0 


860 


+ 


++ 



of weight. The calories were kept at approximately 1000 to 1200, or about 20 
to 24 calories per kg. for SO kg. body weight. The traces of glycosuria indicated 
in the graphic chart were very slight, and were mostly connected with the use of 
thrice cooked vegetables. The tolerance for carbohydrate was so low that 
300 to 500 gm. of vegetables of Joslin's 5 per cent class, boiled through three waters 
in the usual way, brought on these traces of glycosuria. In Jan. these vegetables 
were omitted. The patient being an old woman with small appetite, it was pos- 
sible to place her on a ration made up of coffee, soup, whisky, eggs, meat, fish, 
butter, and olive oil. She remained practically sugar-free on this regimen, since 
the traces of glycosuria noted thereafter were mostly very faint reactions in the 
urine of single periods during the day, undiscoverable if mixed with the 24 hour 
urine. The undernutrition is indicated by the continuous fall in weight during 2| 
months, from 53.5 kg. on admission to 45 kg. on discharge. She was discharged 
on Feb. 1, very happy with her condition. The incipient gangrene had healed 
early, and she had been restored to comfort and activity. She felt able to con- 



246 CHAPTER in 

tinue her diet amid the difficulties of her home conditions. Slight albuminuria 
and casts present on admission still continued at discharge, and the systolic 
blood pressure was 205 mm. 

Subsequent History. — The patient was unable to continue her diet successfully 
at home. As she evidently required continuous care, she was advised to enter 
a semipublic institution, where she has since lived and is kept on a moderately 
restricted diet, with 1 to 3 per cent sugar constantly in the urine and continual 
pain in the right foot, which does not completely disable her and has not been 
accompanied by any return of actual gangrene. 

Acidosis. — ^As respects acidosis, it will be noted that she entered with a nega- 
tive ferric chloride reaction, evidently because of the carbohydrate in her former 
diet. The ferric chloride reaction appeared on the 4th day of fasting, about as 
might be expected in a normal person, and it is again nonceable that 300 calories 
of alcohol did not prevent the appearance of this reaction. The reaction was 
never a heavy one, and in a feeble woman of this age it was not considered ad- 
visable imder the circumstances to impose the rigorous measures which wovdd 
have been necessary to make the urine quickly normal. Theoretically, this con- 
tinued slight acidosis and the diet keeping her barely on the verge of glycosuria 
all the time were wrong, and under ideal conditions actually better results could 
have been achieved by more rigid measures, cutting her diet and weight still 
lower and bringing about a normal state of the urine and at least some slight 
carbohydrate tolerance. Practically, there was a strong likelihood that she 
would not be able to foUow the necessary diet outside the hospital, and it seemed 
therefore unwise to attempt an ideal result. Under the plan pursued, her condi- 
tion at discharge was a good one for her years, and by persisting in the same 
program she would almost certainly have gained gradually some carbohydrate 
tolerance and lost her trace of acidosis; but her mental and social state interfered 
with this result. 

Remarks. — This patient was admitted as presenting early diabetic gangrene 
with seniUty and arteriosclerosis, the idea being to test the effect of therapy in 
such a case. Simple protection and occasiohal hot air baths were the only local 
measures employed, but healing proceeded uninterruptedly and apparently as 
rapidly as possible at this age. It was striking that pain in the foot could at 
first be produced at wiU by food. Excessive diet which brought return of glyco- 
suria was found to bring complaint of pain the same day, although the patient 
was kept ignorant of the laboratory tests. On discharge the foot appeared 
entirely normal, except for coldness to touch and some loss of tissue in the for- 
merly discolored areas. Pain, tenderness, and disability had disappeared. The 
loss of weight under treatment, amounting to about one-seventh of her entrance 
weight, did not serve to weaken her. On the contrary, she went out with improved 
strength. 

The case well illustrates a familiar therapeutic situation. In numerous cases 
of diabetes in advanced senility, in one sense the diabetes is mild, the glycosuria 



CASE RECORDS 247 

is not excessive, the acidosis does not threaten coma, and the patient seems to 
go along for years "with little injury. Some form or degree of harm ordinarily 
results sooner or later, frequently, as in this case, gangrene. On treatment, the 
apparently mild diabetes proves by no means easy to control. The tolerance 
from the standpoint of complete sugar-freedom is surprisingly low, and months 
of privation and reduction of weight and sometimes also of strength are neces- 
dary to atone for the harm caused by years of lack of care. Only three courses 
are open. One is rigorous and conscientious treatment, just as in a younger 
patient. This is diflScult and tedious for both physician and patient; but when 
circumstances permit it to be carefully carried out, the ultimate results are more 
favorable than in younger persons, and the improvement of health and appar- 
ently of longevity prove that the previous glycosuria was not harmless but was 
largely responsible for symptoms attributed to senility or other causes. The 
other extreme is complete disregard of diet. This course may be expected to 
bring death from gangrene or other accident, sometimes even coma, in a large 
proportion of patients. Here again due weight may not be given to diabetes as 
the predisposing cause back of the infection or other terminal condition. The 
middle course is one frequently adopted; namely, a moderate regulation of diet 
with the aim of preserving strength and comfort and not paying too much attention 
to laboratory findings. In the case of this patient, the alleged comfort of such a 
course consists actually in continuous pain in the right foot and the danger of 
gangrene at any time. It is also scarcely reasonable to suppose that the foot is 
the only part of the body injured by the diabetes. 

CASE NO. 18. 

Male, unmarried, age 16 yrs. American; errand boy. Admitted Nov. 18, 
1914. 

Family History. — Grandparents' history not certain. Father died at, 42 of 
cirrhosis of liver. Mother and two sisters of patient alive and well. 

Past History. — Healthy life. Chicken-pox at 6. Tonsillitis in 1912. No 
other iUnesses. Habits regular. No alcohol, very little tobacco. No exces- 
sive sweets or carbohydrate. Never nervous. Ordinary weight 133 pounds. 

Present Illness. — Only 3 weeks ago, during the last week of Oct., first symptoms 
were noticed in the form of thirst, polyuria, polyphagia, weariness, and sleepiness. 
During present month he has been unable to read by artificial light because of 
blurring. Nov. 1, he stopped work and consulted a physician, who found 5 per 
cent glycosuria. Patient claims to have followed restricted diet since then, in- 
cluding gluten bread. He has never become sugar-free. 

Physical Examination. — ^Normal in appearance though rather thin and nervous. 
Teeth in good condition. Tonsils slightly enlarged. A few small palpable 
glands in neck. Knee and AchiUes jerks exaggerated. Blood pressure 135 
systolic, 60 diastolic. Examination otherwise negative. 



248 CHAPTER m 

Treatment. — The diet on Nov. 19 consisted of 105 gm. protein, 17 gm. carbo- 
hydrate, and nearly 2000 calories. The glycosuria diminished to traces, and sugar- 
freedom could doubtless have been readily attained without fasting. Neverthe- 
less, for the sake of more rapid and radical improvement, 4 days of fasting were 
imposed (Nov. 20 to 23). To make the fast easier, thrice cooked vegetables in 
quantities increasing up to 1500 gm. daily were permitted. The trace of ferric 
. chloride reaction which developed cleared up spontaneously. 

On Nov. 24 two eggs and 20 gm. butter were added, increased on the next 
day to four eggs and 40 gm. butter. Meat and bacon were subsequently added. 
The negative ferric chloride reactions, Dec. 1 to 4, on diets of 2200 to 2300 calories 
without carbohydrate and composed chiefly of fat, stand in strong contrast 
with what other patients often show when sugar-free on the same sort 
of diet. Thereafter the patient proved able to tolerate as much as 2900 
calories with 60 to 80 gm. carbohydrate and 107 to 130 gm. protein. He was 
dismissed on approximately this diet but with calories diminished to about 2500. 
. General instructions were given, but the food was not required to be weighed. 
The liberal diet (over 2 gm. protein and 50 calories per kg.) was permitted with 
the idea of satisfying the patient and allowing him to work hard, and in the hope 
that it might be tolerated in view of the early and mild stage of the diabetes. 
The average was reduced slightly by the fast-day ordered ev^ry 2 weeks. Also 
instead of weighing food, the patient was instructed to keep careful account of 
his own weight and never let it go above 120 pounds {i.e. 13 pounds below his full 
normal weight). Any gain over this was to be checked by fasting and reduced 
diet. 

Subsequent History. — Reports indicated that the patient adhered to his diet 
until cherries became ripe in summer, when he started glycosuria by eating cher- 
ries. As he then broke diet in other respects, he was instructed to return to the 
bospital on July IS. 

Second Admission. — In addition to glycosuria, decided ketonuria was present 
this time, notwithstanding 125 gm. carbohydrate in the diet on July 16. 3 days 
of fasting with nothing but cofiee and soup were imposed Quly 18 to 20), followed 
by a carbohydrate tolerance test, starting with 20 gm. carbohydrate in the form 
of green vegetables. The quantity was increased by 20 gm. carbohydrate daily, 
until on Aug. 4, 350 gm. carbohydrate were taken without glycosuria. Without 
attempting to push the carbohydrate higher, a fast-day was given on Aug. 5, with 
only coffee and soup. A diet was then instituted of 100 gm. protein, 100 gm. car- 
bohydrate, and 2600 calories. Later the carbohydrate was raised as high as 200 
gm. Traces of glycosuria occurred on this diet. It is noteworthy that even with- 
out glycosuria and with this high carbohydrate intake, some distinct ferric 
chloride reactions were present. On Aug. 21, the carbohydrate was diminished 
to 5 gm., the protein remaining about 100 gm., and the total diet about 2500 
calories. On Aug. 28, 100 gm. carbohydrate were resumed, and the protein and 
total diet diminished to 84 gm. and 2400 calories respectively. The patient was 



CASE RECORDS 249 

discharged on this diet. His weight was 56 kg. at this admission, {i.e. a return 
to his full normal weight which had been forbidden) and 51.8 kg. at discharge 
(still about 1 kg. higher than at his first admission) . 

Subsequent History. — Nothing further was heard from the patient until a letter 
from his sister.reported his death on Nov. 11, 1915. Inquiries revealed that the 
mother had no control over the boy, who refused to foUow diet or allow his urine 
to be tested. The physician who referred the boy to this hospital was out of 
town. After the usual polyuria, polydipsia, and loss of weight and strength, the 
patient late in Oct. began complaining of indigestion, and a few days before death 
showed a high degree of nervousness and excitement. A local physician treated 
these symptoms of acidosis with tablets for the indigestion, sedatives for the 
nervousness, and tonics for the weakness. Heavy breathing was noted at the end, 
but actual coma was only a few hours in duration. 

Remarks. — ^The condition was at a very early and favorable stage when treat- 
ment was begun. The well marked ferric chloride reactions without glycosuria 
on the high carbohydrate diets of Aug. 16 to 20 possibly indicate the intrinsic 
severity of the case. Undoubtedly the violations of diet and the gain in weight 
between the two admissions constituted a serious setback. Nevertheless, the 
carbohydrate test up to Aug. 4 showed that the tolerance was still high, and the 
blood sugar later in Aug. was found to be easily brought to normal. The later 
course was the t3rpical uninterrupted downward progress of severe untreated dia- 
betes, owing entirely to the fault of the patient and of the local practitioner who 
then treated him. No dietetic treatment could accomplish anything in a patient 
so irresponsible as this. 

Concerning the diets prescribed in the hospital the following may be re- 
marked. The change to practically carbohydrate-free diet on Aug. 21 is the 
typical old-fashioned method. It is observed that in spite of the high caloric 
intake (nearly SO calories per kg.) the blood sugar promptly fell to normal and 
the results might be called favorable. The fact is that the ferric chloride reaction 
persisted, and continuance of such a high intake would inevitably have brought 
disaster later, no matter how favorable the laboratory findings for the time being. 
The diets allowed this patient were unduly high, for the following reasons. First, 
it had not yet been established whether the patient at such an early stage might 
recover sufficient tolerance to carry the fuU load of diet and weight. Second, this 
patient was given exercise involving considerable labor (see Chapter V), and it 
was anticipated that he would perform considerable muscular work at home. 
Third, it was evident from his general character that he would not endure any 
real privations, and he was therefore placed on a diet which left no excuse for 
violations, being fuUy satisfactory in protein, carbohydrate, and total quantity, 
and calling only for abstinence from sugar and reasonable limitation of starch. 
As stated, later experience has made it evident that such treatment is bad, and 
always results in the downward progress which was formerly regarded as spon- 
taneous and inevitable. The attempt to try this method in this case failed on 
account of the patient's disobedience. 



250 CHAPTER ni 



CASE NO. 19. 



Female, married, age 39 yrs. Russian Jew; housewife. Admitted Nov. 18, 
1914. 

Family History.— Pa.ients lived to old age. Patient had four brothers and nine 
sisters; all are living or died of typhus or accidental causes in Russia. No dia-» 
betes, cancer, tuberculosis, syphilis, or nervous diseases known in family. 

Past History.— Born in Russia; came to United States 26 years ago. Hy- 
gienic surroundings poor. Measles and whooping-cough in childhood. Typhus, 
at 12. 16 years ago a so called abscess in throat, said to have been cured by 
lancing. 7 years ago patient had a convulsion after a confinement; had to be in 
hospital 3 weeks and was sick for 3 months. Some shortness of breath on exer- 
tion for 2 years past. She was married 18 years ago. Husband Uving and well. 
Four children living and well; one born dead, full term; one miscarriage. Habits 
regular, no excesses. Frugal diet, poor in sweets but also in vegetables. 

Present Illness. — ^Began with pruritus vulvae li years ago. A doctor pre- 
scribed a salve which was ineffective. 1 year ago polydipsia commenced. She 
drank 60 glasses of water a day. Polyphagia began 6 months ago. She has lost 
38 pounds during the past year, falling from her normal weight of 146 pounds 
to 108 pounds. Sleeplessness, weakness, pains in back also complained of. She 
consulted two different physicians who, notwithstanding these typical symptoms, 
told her she was "run-down" and prescribed tonics without examining urine. 
4 weeks ago she came to New York for further medical advice. Diagnosis of 
diabetes was made and she was in a hospital for 2 weeks on a diet limited abso- 
lutely to meat, eggs, fish, cream, cheese, and string beans. Her condition failed 
to improve, and on her physician's advice she made apphcation at this Institute. 
Her chief complaints are extreme weakness and persistent headaches. 

Physical Examination. — A well developed woman without evident discomfort 
or dyspnea, appearing only sUghtly undernourished, but with flabbiness of skin 
indicating considerable loss of weight. Nephritic countenance, with slight edema 
about eyes and general pallor. Ocular examination negative. Teeth show 
neglect; many missing; those remaining show caries and pyorrhea. Throat ap- 
pears normal. Heart normal. Slight empyema. Reflexes normal. Examina- 
tion otherwise negative. Blood pressure 90 systolic, 70 diastolic. Wassermann 
negative. 

Treatment. — (No graphic chart.) On her first day in hospital (Nov. 18) the 
patient received a carbohydrate-free diet of 12 gm. protein and 411 calories, and 
excreted 8.3 gm. sugar. Notwithstanding the great weakness complained of and 
the presence of nausea and colic, fasting was begun the next day and continued 
for 5 days. Alcohol was permitted because of weakness, but not more than 80 
cc. whisky per day could be taken because of nausea. The ferric chloride reaction 
was negative on admission, positive on the first fast-day and diminished so that 
it was fully negative like the sugar reaction on the 3rd day of fasting. 180 gm. 



CASE RECORDS 251 

thrice cooked vegetables were given on the 4th and 5th days. A very low diet 
was then begun, consisting of two eggs and 500 gm. thrice boiled vegetables. 
The weight, which was 47.2 kg. on admission, diminished to 44.6 kg. on Nov. 24. 
The patient complained of great hunger. The diet was rapidly increased until on 
Dec. 5 it consisted of 60 gm. protein, 2 gm. carbohydrate, and 3600 calories. 
This was tolerated without glycosuria or ketonuria, but the carbohydrate toler- 
ance was very low. On Dec. 7 the addition of 200 gm. green vegetables con- 
taining 9.8 gm. carbohydrate resulted in shght glycosuria. The weight by this 
time was up to 48.8 kg. and the patient was much improved subjectively. The 
glycosuria was checked by a fast-day with 45 cc. whisky, then carbohydrate-free 
diet resumed, at first very low (25 gm. protein and 250 calories), but again rapidly 
increasing until on Dec. 19 it contained 138 gm. protein and 3330 calories. The 
attempt to include 7 to 12 gm. carbohydrate in the form of green vegetables 
again resulted in slight glycosuria. Without a fast-day, the carbohydrate was 
stopped and the total diet diminished to 600 calories, followed by an increase as 
before. On Dec. 28 the weight was 47.4 kg., and a diet of 100 gm. protein and 
22 gm. carbohydrate were tolerated without glycosuria. The same was true of 
the diet of 91 gm." protein and 27 carbohydrate on Dec. 29. The assimilation of 
carbohydrate here is explainable by the lower weight and the lower total diet; 
namely, 2200 calories on each of these days. Likewise 103 gm. protein, 24 gm. 
carbohydrate, and 2400 calories were tolerated on Dec. 30. The patient was 
discharged on Jan. 3, 1915, on a carbohydrate-free diet of 110 gm. protein and 
2500 calories, with 600 to 800 gm. thrice cooked vegetables daily. She felt well 
and fit for work and was continuously free from both glycosuria and ketonuria. 
Her weight at discharge was 47.6 kg., or practically identical with the weight at 
admission. 

Subsequent History. — The patient followed her diet faithfully, and on Apr. 20 
the addition of 10 gm. carbohydrate was permitted. Her weight tended to in- 
crease, and was 50.4 kg. on Aug. 2, 1915, and 55.8 kg. on Jan. 11, 1916. She was 
then instructed to take a fast-day once every 2 weeks. One feature of her his- 
tory is that 7 weeks after discharge (Feb., 1915) and again in Nov., 1915, she had 
severe colds or grippe with fever, which confined her to bed 1 or 2 weeks, while 
no more than traces of glycosuria appeared. Her progress continued steadily 
favorable, and in Jan., 1916 she was referred to another clinic for further guidance 
and observation. She was seen again in Apr., 1918, still following diet and doing 
her housework without complaint. 

Remarks. — The case gives the usual illustration that the way for a weak and 
undernourished diabetic to gain strength and well-being is by therapeutic under- 
nutrition. Abrupt initial fasting is sometimes dangerous in patients showing the 
condition here described at the outset, but was well borne in this instance. With 
sugar-freedom and loss of weight, the patient felt distinctly better; and in view 
of her age and the relative mildness of the case it was considered safe to augment 
her diet rather rapidly. As is frequent in such cases, with an adequate ration of 



252 CHAPTER ni 

protein and calories, the carbohydrate tolerance was practically nil. With the 
weakened condition and the apparent absence of tolerance, this might have been 
classed in standard text-books as a severe case. The relative mildness was 
shown by the steady improvement when the urine was merely kept sugar-free. 
It is also of interest that occasionally patients of this sort, handicapped by ignor- 
ance and poverty combined, prove able to follow diet with fidelity, test their urine 
conscientiously, and achieve satisfactory results. 

CASE NO. 20. 

Female, married, age 38 yrs. American; housewife. Admitted Nov. 19, 
1914. 

Family History. — One brother died of tuberculosis at 29 years of age. Family 
otherwise healthy. 

Past History. — Scarlet fever, measles, chicken-pox, whooping-cough, and 
diphtheria all before 7th year. Also at age of 2 patient had a fall injuring left 
knee so that she was unable to walk until 13, and the leg is stiU stiff. Has had 
headaches all her life. Lately they are limited to the menstrual period, and are 
localized in migraine fashion on the left side of the face. Numerous sore throats 
during the past year. Habits regular. No excesses, no special fondness for 
sweets or starches. Married 13 years ago. One child born 12 years ago died of 
heart trouble a few hours after birth. A second living and well. Venereal dis- 
eases and symptoms denied. 

Present Illness. — Glycosuria was discovered 1 year ago when patient went to a 
hospital for another cause. Since then there have been no symptoms except the 
gradual loss of SO or 60 pounds of weight. She has noticed a darkening of the skin 
about her eyes during this time. This began in the form of small dots which have 
increased and fused until they form a very noticeable broad brown ring around 
her eyes. She has been on a moderately restricted diet with continuous glycosuria, 
and has been taking sodium bicarbonate and citrate for the past few weeks. 
Nervousness has developed and she tires easily. She was referred to the Insti- 
tute by her physician on suspicion of bronzed diabetes. 

Physical Examination. — Height ISO cm. A nervous, frightened looking woman, 
well nourished, with sweetish odor of breath. Shghtly elevated bronzed circle 
1| to 2 cm. wide about both eyes is most striking characteristic of face. Teeth 
neglected, three missing, one carious; no pyorrhea. Throat normal. Heart 
shows signs of well compensated mitral regurgitation. Blood pressure 140- 
110. No enlargement of lymph nodes except in axilla. Knee jerks present 
on right, absent on left (injured side). Examination otherwise negative. No 
pigmentation except that about eyes. 

Treatment. — Patient was first kept on an observation diet without fasting. 
No special pecuharities were noticed, and she was able to tolerate 75 to 80 gm. 
protein, 30 to 40 gm. carbohydrate, and 1500 to 1800 calories with no glycosuria 



CASE EECOEDS 253 

or only traces. Ketonuria was stubbornly persistent but never dangerous in de- 
gree. Slight albuminuria present on admission cleared up completely and did not 
return. The observation diet as a whole represented undernutrition, inasmuch 
as the weight fell from 53 kg. at entrance to 48.5 kg. on Dec. 18. The condition 
about the eyes proved to be xanthelasma, and nothing was found to indicate a 
true bronzed diabetes. Accordingly a more radical treatment was instituted in 
the latter part of Dec, especially with a view to reducing weight. From Dec. 20 
to Jan. 6 the diet contained nothing but whisky and green vegetables. Traces of 
glycosuria appeared when the carbohydrate intake was approximately 60 gm. 
By this means the urine was at last made free from both sugar and ferric chloride 
reactions (Jan. 5 and 6). Carbohydrate was then excluded by thrice boiling the 
vegetables, and two eggs were added. The diet was then built up, so that on 
Jan. 13 to 14 it consisted of about 80 to 90 gm. protein, 30 gm. carbohydrate, 60 
gm. alcohol, and 2200 to 2300 calories. The weight had thus been reduced to 
46.6 kg.; i.e., a loss of 6.4 kg. since admission. Though the ferric chloride reac- 
tion had reappeared, it was deemed safe to let the patient go home on this theo- 
retically excessive diet, in order that she might carry on her housework comfort- 
ably and continue to improve in strength and nervous control, the expectation 
being that in such a case and under such conditions the gradual gain in tolerance 
resulting from continued sugar-freedom would take care of the persisting ab- 
normalities, notably the ketonuria. 

Subsequent History. — The patient adhered faithfully to her diet at home, car- 
ried on her housework, nursed her daughter through pneumonia, gradually lost 
her nervousness, and remained continuously free from glycosuria but with a 
slight ferric chloride reaction constantly present, even with addition of 10 gm. 
carbohydrate to the diet on Apr. 20. On June 2 she was readmitted to the hos- 
pital because of complaint that she was not feeling so well and that her nervousness 
was returning. 

Second Admission. — The weight at this admission was 43.8 kg.; i.e., 2.8 kg. 
less than at discharge. The general condition was much better than at the former 
admission. The pigmentation about the eyes appeared neither to have increased 
nor diminished. The urine was entirely free from sugar, as the patient reported 
it had been continuously, but the ferric chloride reaction had become heavy, and 
the 24 hour urine contained 1.96 gm. ammonia nitrogen. The symptoms com- 
plained of were presumably associated with this acidosis. It was therefore 
deemed desirable to proceed radically to abolish acidosis. This could not be 
done by simple addition of carbohydrate to the diet, for on June 3 the giving of 
30 gm. carbohydrate with 84 gm. protein and 1700 calories caused well marked 
glycosuria. On the other hand, the acidosis diminished by simple reduction of 
diet, so that on June 5, on a carbohydrate-free diet of 66 gm. protein and 1300 
calories, there was excretion of only 0.56 gm. ammonia nitrogen. Therefore on 
June 6 and 7, fast-days were given, with an allowance of 300 cc. coffee, 300 cc. 
clear soup, and 50 cc. whisky. On Jime 8, alcohol was discontinued and never 



254 CHAPTER III 

again used for this patient. Green vegetables representing 10 gm. carbohydrate 
were added on this day, and the usual carbohydrate tolerance test was instituted, 
with increase of 10 gm. carbohydrate in green vegetables daily. A trace of gly- 
cosuria appeared on June 14 with 90 gm. carbohydrate, but this did not represent 
the true limit of tolerance, because glycosuria ceased, and the true limit was 
reached only with about 150 gm. carbohydrate on June 23. Further increase 
up to 170 gm. on the following days caused only slight but continuous glyco- 
suria. Under this program the ferric chloride reaction became negative and the 
ammonia excretion held a low level. After a fast-day on June 28, a regular 
diet was gradually built up with one fast-day every week. Even with 37 to 45 
gm. carbohydrate in the diet the ferric chloride reaction reappeared, but dimin- 
ished, and on July 13 became negative with 67 to 75 gm. carbohydrate in a diet 
otherwise composed of 75 to 100 gm. protein and 1600 to 2100 calories. The 
weight on July 24 was 41.8 kg.; i.e., a loss of 2 kg. during this period in hospital, 
or a loss of 11.2 kg. since her first admission. She was discharged to continue 
this diet at home. 

Subsequent History. — The patient continued to follow treatment faithfully, 
and improvement continued with constantly normal urine. She passed through 
an attack of grippe in Nov., 1915, without return of glycosuria. She has led a 
fully normal life except for attention to diet, does her work easily, has lost all ner- 
vousness, and feels well in every respect. In addition to her reports, she came 
for personal examination on July 18, 1916. Her weight was then 45.2 kg.; i.e., 
a gain of 3.4 kg. since discharge. Her general appearance was excellent, with pig- 
mentation unchanged. The urine was normal, the CO2 capacity of the plasma 
50.3 per cent, the plasma sugar 0.189 per cent. This hyperglycemia received no 
special treatment, for since there had been such obvious improvement before, it 
was considered probable that it would continue, with ultimate reduction of blood 
sugar, without more radical measures in a case of this type. 

Remarks. — ^Aside from points abready noted, the case again illustrates the 
benefit resulting from general therapeutic undernutrition in a patient who had 
already suffered considerable loss of weight and strength from diabetes. Both 
the treatment and the improvement were gradual in character. Results could 
have been achieved more quickly by following up the alcohol-carbohydrate period 
of Dec, 1914, with undernutrition sufficient to keep the ferric chloride reac- 
tion negative, at the same time buUding up carbohydrate tolerance more rapidly. 
As usual in such cases, however, the simple continuance of freedom from gly- 
cosuria brought steady improvement, so that at the second admission there was 
a considerable carbohydrate tolerance and acidosis was easily abolished without 
interruption of the steady gain in well-being. The patient now weighs enough 
for fully satisfactory looks, comfort, and strength. There is a complete con- 
trast in these respects with her former condition at a higher weight. An at- 
tempt to return to the former weight would doubtless bring a return of the 
previous troubles. There has probably been little or no absolute improvement 



CASE RECOEDS 255 

in the power of assimilation, neither is there any evidence of any progressive 
•decline. The patient is merely living within her assimilative power. As far as 
-can be judged from the experience of nearly 3 years, she can continue to do so 
without difficulty, and the general trend seems to be upward rather than 
•downward. 

CASE NO. 21. 

Female, married, age 46 yrs. Scotch,* housewife. Admitted Nov. 20, 1914. 

Family History. — Father died in accident. Mother died of heart trouble at 
42. Patient was the only chUd. Diabetes, tuberculosis, cancer, syphilis, or ner- 
vous disorders in any relatives denied. Patient married twice. Has had only 
one child, who is alive and well; no miscarriages. 

Past History. — Measles, mumps, and whooping-cough in childhood. Came 
from Scotland to United States at age of 17. Scarlet fever 15 years ago. Op- 
eration for ventral hernia 1 year ago. Subject to occasional headaches ever since 
she can remember. Also has shortness of breath on exertion. Occasional sore 
throats. No use of alcohol. Drinks six or eight small cups of tea daily. Up to 
15 years ago weight was 146 pounds; since then it increased, so that at the time 
of her operation a year ago it was 266 pounds. During this year she has lost 
36 pounds. 

Present Illness. — ^About 6 months ago patient began to notice polyuria, poly- 
•dipsia, polyphagia, and increasing nervousness, with rapid loss of weight. These 
have been the only symptoms. No treatment by diet. 

Physical Examination. — ^Height 155 cm. A large framed, plethoric, obese 
woman with dry skin, a nervous expression, and bilateral arcus senilis. Teeth 
neglected, some missing; those remaining show caries and pyorrhea. Tonsils a 
trifle hypertrophied. Slightly large thyroid palpable. No lymph node enlarge- 
ment. Heart slightly enlarged. Slight emphysema. Knee jerks active. Leg 
veins markedly varicosed. Blood pressure 175 systolic, 120 diastolic. Trace of 
albumin in urine, but no casts. 

Treatment. — ^The most obvious requirement was to reduce weight. The most 
noteworthy initial observation was that in 4 days of absolute fasting this very 
•obese woman failed to develop any ferric chloride reaction and showed abso- 
lutely no symptoms of acidosis. On the following 4 days she received only mod- 
erate quantities of whisky (not above SO gm. alcohol) . It is evident that they did 
not prevent the appearance of a slight ferric chloride reaction. This reaction was 
(negative on Nov. 28, when only 10 gm. alcohol were given, as if the larger quan- 
tities of alcohol had tended to produce rather than prevent it. On Nov. 29, a 
•carbohydrate-free diet of 93 gm. protein and 2260 calories caused a trace of 
glycosiuia. The subsequent diets represent very marked undernutrition. It is 
obvious from the graphic record that the patient not only had practically no car- 
bohydrate tolerance but also tended to show traces of glycosuria even on very 
low carbohydrate-free diets. She was of the type spoken of in older text-books 



256 CHAPTER in 

as relatively independent of diet ("paradoxical tolerance"). That is, her glyco- 
suria had never been excessive, and if tested she would doubtless have proved her 
abihty to assimilate most of the carbohydrate of any diet. Yet complete sugar- 
freedom was difficult to achieve even with the most radical restrictions. Blood 
sugar analyses were not made. It is probable that a continuous marked hyper- 
glycemia was responsible for the frequent traces of glycosuria, and that this 
varied Uttle with diet. The principal result of treatment was to bring the body 
weight down from 108 kg. to 90 kg. No special attempt was made to conserve 
the body protein. Nitrogen balances would undoubtedly have turned out strongly 
negative. Nevertheless, there was a gain in well-being, and at discharge there were 
no symptoms except those referable to arteriosclerosis, the former migraine attacks, 
and other conditions apparently independent of the diabetes. The diet pre- 
scribed at dismissal was approximately 75 gm. protein, 60 gm. carbohydrate, and 
1300 calories, representing, for a weight of 90 kg., only about 0.8 gm. protein and 
IS calories per kg. The trace of glycosuria on Jan. 24 may be regarded as of 
the accidental type sometimes resulting from a sudden increase of carbohydrate. 
It appeared that the patient could carry this diet without glycosuria and with a 
bare trace of ferric chloride reaction. She stated that her appetite was reasonably 
well satisfied, and she felt better when eating and weighing less. The trace of 
albumin present in the urine at admission remained unchanged, but casts could 
very seldom be found. The treatment was not considered complete at dismissal, 
but undernutrition was to be continued at home. 

Subsequent History. — The patient continued free from glycosuria at home, 
with a persisting trace of ferric chloride reaction. She was not required to weigh 
her food, and her estimates were probably enlarged with increase of appetite, for 
her weight at first held practically even, being 90.6 kg. in Aug., 1915. By Oct. 
there was an increase of 2.6 kg. The sugar in the whole blood was then 0.128 per 
cent, in the plasma 0.161 per cent. Sugar remained absent from the urine; the 
ferric chloride reaction continued present. She was instructed to fast 1 day every 
2 weeks." 

On Nov. 29, the weight was found to be 101.4 kg., plasma sugar 0.143 per cent, 
CO2 capacity of plasma 43.2 per cent. The blood pressure was 240 systolic, 140 
diastolic, and there had been symptoms referable to hj^jertension. She was 
instructed to fast IJ days every week. 

On Jan. 11, 1916, the blood pressure was 220 systoUc, 120 diastolic. The weight 
was 101.5 kg. with clothing, 99 kg. stripped. She was instructed to remain in bed 
for a week on a diet of nothing but low percentage green vegetables. The urine 
was entirely negative for both sugar and ferric chloride reactions. 

On July 13, 1916, the blood sugar was 0.128 per cent, plasma sugar 0.156 per 
cent, CO2 capacity 56.9 per cent. Sugar and ferric chloride reactions in urine 
remained negative. Though recent dietary instructions theoretically estab- 
lished an intake of only 1000 calories, the patient's estimates were evidently too 
high and the weight continued to rise, being now 103.2 kg. stripped. The patient 



CASE EECORDS 257 

has remained so well that she has not been closely supervised. She still con- 
tinues to lead a normal life, and suffers only from headaches and occasional attacks 
referable to hypertension. 

Remarks. — Complication of this case with obesity and arterial hypertension 
called for no special alteration in the treatment of the diabetes. The entire 
condition rendered a reduction of weight desirable. By this simple measure 
the carbohydrate tolerance, which appeared so very low, was easily raised, and 
the case stood revealed in its true light as one of intrinsically mild diabetes. It 
must again be mentioned that the initial stage of treatment of such a case some- 
times presents difficulties and dangers such that fasting may have to be em- 
ployed cautiously and after special preparation; but in this instance the fasting 
offered no difficulty and the obesity was no obstacle to the gradual disappearance 
of the ferric chloride reaction. The case thus opposes the idea that the available 
' fat supply is the sole determining factor in fasting acidosis. Under a mild thera- 
peutic regime hj^perglycemia has been persistent. It need not be attributed in 
any degree to the hypertension; on the contrary, the hyperglycemia sometimes 
described in cases of hypertension is more probably an indication of pancreatitis 
and mild diabetes. This being one of the earlier cases of the series, conservatism 
seemed to favor leniency in the treatment. Fuller experience indicates that the 
right plan would be to reduce the weight sufficiently to keep the blood sugar nor- 
mal. Nevertheless, in view of the mUdness of the case, if the patient follows a 
fairly reasonable diet without letting her weight rise too high, she can probably 
go through life without further trouble from her diabetes. 

CASE NO. 22. 

Male, married, age 52 yrs. American Jew; cigar manufacturer. Admitted 
Nov. 20, 1914. 

Family History. — Father died of pneumonia at 74. Mother, now 74, has kid- 
ney trouble. One brother living and well. Two sisters died in childhood, a 
third of appendicitis at IS, a fourth is living but has carcinoma of breast. No 
tuberculosis, syphilis, or nervous disorders in family. Patient has been married 
31 years; wife living and well. Five children; one died of diphtheria in infancy, 
four living and well. 

Past History. — Practically never sick from childhood up. Neisser infection 
twice. Syphilis denied. At age of 21 patient was rejected for life insurance 
because of alleged B right's disease. He consulted eminent specialists, and the 
slight albuminuria was classified among the earliest examples of orthostatic al- 
bimiinuria. For many years he has never been without albumin and casts in 
urine, but has had no symptoms other than these and has never had to miss a 
single day from business. For part of his life patient drank considerable wine in 
connection with business dealings, and smoked IS to 20 cigars a day. He started 
as a poor boy and became a millionaire, and has lived at highest nervous tension. 



258 CHAPTER III 

In the past 10 or 12 years he has had 25 or 30 hysteric attacks in which he was 
practically irresponsible. He is accustomed to rich Uving. Bowels constipated. 

Present Illness. — 2 years before admission sjrmptoms began with extreme 
himger and thirst, loss of weight, bad breath, and cramps in the legs. On ac- 
count of failing vision he consulted an oculist, who immediately asked for a 
specimen of urine and diagnosed diabetes. The diet since then has been sUghtly 
restricted qualitatively, but quantitatively two or three times as much as re- 
quired by a normal appetite. The loss of weight has continued nevertheless. 

Physical Examination. — ^A shghtly buUt, somewhat emaciated man with pale 
complexion and nervous, feeble appearance. Several teeth missing; those pres- 
ent show sUght caries and pyorrhea. Throat somewhat congested; left tonsil not 
visible, right protrudes slightly. Shght generalized lymph node enlargement. 
Heart very shghtly enlarged to left. Arteries palpably sclerosed. Blood pres- 
sure 135 systoUc, 110 diastohc. Liver edge 2 cm. below costal margin. Reflexes 
normal. Examination otherwise negative. Urine shows shght albumin and 
numerous hyahne casts. 

Treatment. — The patient's extreme nervousness, as also headaches and ter- 
rors at night, required the use of codeine during the early days in the hospital. 
He was kept on an observation diet for the first 3 days, poor in carbohydrate, and 
particularly with total calories limited to about 1600 on Nov. 21 and 900 on 
Nov. 22. The glycosuria was thus greatly diminished. Nevertheless fasting was 
instituted as soon as the general condition seemed to permit. Owing to weak- 
ness, the patient was in bed during the fast. On Nov. 23 and 28 the fasting 
was absolute. On the intervening days whisky was given, but never above 70 
cc. Glycosuria ceased with the first day of fasting. With continuance of the 
fast, the ferric chloride reaction diminished to traces. On Nov. 29 a carbohy- 
drate-free diet of 45 gm. protein and 2080 calories was tolerated without glyco- 
suria, but brought back a heavy ferric chloride reaction. On the next day the 
diet was diminished to 23 gm. protein and 600 calories. The weakness and 
nervousness stiU being salient features and the patient being very hungry, a lib- 
eral diet was permitted on the subsequent days, rising by Dec. 19 to 97 gm. pro- 
tein, 33 gm. carbohydrate, and 3000 calories. Traces of glycosuria were fre- 
quent on this high diet, and well marked ferric chloride reactions continued. By 
this time the general condition had improved and the patient had grown more 
accustomed to hospital hfe and dietary restrictions. Accordingly, on Dec. 21 a 
more rigid treatment of the diabetes was undertaken. On that day the only 
food was 50 gm.. alcohol. Green vegetables were gradually added to the alcohol, 
representing 7.5 gm. carbohydrate on Dec. 22 and increasing to 107 gm. on Dec. 
28. The ferric chloride reaction was still stubborn notwithstanding this car- 
bohydrate intake without glycosuria — an illustration that food is not the only 
controlling factor. In view of the patient's weakness and irritability a more 
Uberal diet was again resumed. He was dismissed on Jan. IS, 1915, on a diet of 
approximately 100 gm. protein, 15 gm. carbohydrate, and 2400 calories. The body 



CASE RECORDS 259 

weight was SO kg. at admission, 47.2 kg. at discharge, the period of treatment thus 
representing undernutrition to the extent of a loss of 2.8 kg. weight. There had 
been a notable gain in strength, so that the patient was now outdoors daily and 
was becoming restless owing to a desire to return to work. The nervousness was 
greatly lessened and he felt that hfe was again worth hving. Albuminuria and 
casts persisted, but several functional tests during the stay in hospital had shown 
a normal index of urea excretion. The patient, being stiU weak, was instructed 
not to work more than half of each day and to pay attention to rest and general 
hygienic measures. 

Subsequent History. — ^The urine continued negative to sugar and ferric chloride 
tests, with the usual albumin and casts present. By Feb. 10 the weight had 
risen to 53.2 kg. The blood pressure was 153 systoUc. The patient at this time 
was working 6 or 7 hours a day, was taking horseback rides and other exercise, 
and reported himself free from nervousness, sleeping soundly at night, and en- 
joying life. In appearance he was very greatly improved. By Apr. 12 there had 
been a further increase of 2 kg. in weight. The blood pressure was 180 systolic, 
135 diastohc. He was warned that the gain in weight was contrary to instruc- 
tions, and the diet was ordered changed to 115 gra. protein, 20 gm. carbohydrate, 
and 1600 calories; i.e., the protein and carbohydrate were slightly increased and 
the fat decidedly diminished. This allowance of about 30 calories per kg. was 
expected to maintain his nutrition without further increase of weight. On July 7 
the patient reported that he had been f eeUng as well as in his earlier years be- 
fore the onset of diabetes. Occasional headaches recurred but were reheved by 
catharsis. There had been a further sHght increase of weight up to 54.4 kg. 
The blood pressure was 195 systolic, 160 diastolic. The patient had departed 
sUghtly from diet, particularly by adding bread occasionally, and the urine showed 
a trace of glycosuria and a moderate ferric chloride reaction. This trace always 
disappeared with a single fast-day, and he was warned to adhere to diet and keep 
sugar absent. 

Second Admission. — ^The patient made no further report until he reentered the 
hospital Jan. 24, 1916, slightly more than a year after discharge. He had car- 
ried on his large business continuously and efl&ciently during this time and also 
had enjoyed much recreation. He returned with glycosuria again present, in con- 
sequence of too many visits to restaurants in the course of his amusements. The 
weight was 50.2 kg.; i.e., 0.2 kg. more than at previous admission. He had been 
running down lately by reason of his indiscretions in diet, but nevertheless was far 
stronger and in better condition in all respects than at his previous admission. 
Physical examination practically as before. Blood pressure 200 systohc, 135 dias- 
tolic. AU the conditions being more favorable, measures were now instituted for a 
radical clearing up of both glycosuria and ketonuria. 4 days of absolute fasting 
were imposed (Jan. 28 to 31). This was followed by a carbohydrate period in 
the form of the usual tolerance test, i.e. on Feb. 1 green vegetables were given 
containing 10 gm. carbohydrate, and this was increased by 10 gm. daily. The 



260 CHAPTER rn 

traces of glycosuria on Feb. 4 and 5 were accidental in character and disap- 
peared with further increase of carbohydrate intake. A tolerance of 150 gm. 
carbohydrate was thus demonstrated on Feb. 15. By this time the ferric chloride 
was entirely negative, the blood pressure had gradually diminished to 160 sys- 
tolic, 120 diastolic, and the patient was feeling well enough to have recovered 
from the fears which had brought him back to the hospital. Accordingly at this 
point he suddenly announced that urgent business matters required his attention 
and that he must leave immediately. He was therefore discharged on the fol- 
lowing day with instructions not to return. 

Third Admission. — ^Nothing more was heard from him until on Oct. 17, 1916, 
his wife telephoned that he had had an attack of apoplexy and was in a critical 
condition. He was found in an excessively excited state, with partial right sided 
hemiplegia. The body weight was again 50.2 kg.; the blood pressure 190 systolic, 
125 diastolic, the blood sugar 0.305 per cent, the CO: capacity of the plasma 81 
per cent. Xhe urine showed moderate sugar and negative ferric chloride reac- 
tions. He was placed on a diet of 65 gm. protein, 10 gm. carbohydrate, and 1000 
calories. On this diet glycosuria diminished to only occasional traces, but the 
blood sugar never fell below 0.2 per cent. Only slight glycosuria resulted from 
an increase of diet to 65 gm. protein, 35 gm. carbohydrate, and 1600 calories. 
Meanwhile, with rest, the paralysis was gradually clearing up. In Dec. and Jan. 
it seemed feasible again to undertake thorough treatment of the diabetes. A 
week of fasting (Jan. 7 to 13) was well borne. At the end of it the ferric chloride 
reaction was negative, the ammonia nitrogen excretion only 0.12 gm., the plasma 
bicarbonate 68 per cent, but the blood sugar was stiU 0.222 per cent. A car- 
bohydrate test with the usual increase of 10 gm. daily showed a tolerance of 
only 30 gm. carbohydrate in the form of green vegetables. Treatment was con- 
ducted according to the usual principles, the protein being kept low (50 gm. or 
less daily) partly on account of the renal condition. Rigorous imdernutrition 
brought the usual results, so that in Feb. a tolerance of 120 gm. carbohydrate 
was demonstrated, and the stubborn hyperglycemia was at last reduced, not to 
normal, but well below the renal threshold. By Mar. the patient was able to 
tolerate 65 gm. protein, 10 gm. carbohydrate, and 1400 calories. His weight had 
been reduced to 41 kg.; i.e., a loss of 9.2 kg. The paralysis had gradually di- 
minished so that he was able to be about again and to make some use of his 
right arm. He was improved sufficiently that he was no longer trustworthy in 
regard to diet. He was discharged with the feeling that life could not be greatly 
prolonged. 

Remarks. — ^The case represents the treatment of diabetes in the presence of 
nephritis. It is evident that such a combination presents no obstacle to the 
carrying out of the usual method. A diet low in both protein and calories is 
beneficial from the standpoint of both the diabetes and the nephritis, and there 
is no antagonism in any of the measures required. In this instance the patient 
was saved from threatening weakness and nervous collapse connected with his 



CASE RECORDS 261 

diabetes, and it was possible, as shown especially in the second admission, to 
make the urine normal and bring the blood sugar also to a normal level. Disaster 
came from the side of the nephritis. The patient is failing but was alive at 
last report. 

CASE NO. 23. 

Male, married, age 44 yrs. American; insurance agent. Admitted Nov. 27, 
1914. 

Family History. — Father and mother living and well. One sister died in in- 
fancy, and a brother of pneumonia. No diabetes or other special disease in 
family. Patient married 20 years. Two children, one living and well at 17 
years; the other died in a difficult labor. An interesting addition to this history 
at time of admission is that patient's mother has since developed diabetes at the 
age of 74. 

Fast History. — Measles, mumps, and chicken-pox in childhood. Healthy life. 
Neisser infection at 19; syphilis denied. 14 years ago had "bloody dysentery" 
for a week. Habits regular; moderate drinking and smoking. Appetite normal. 

Present Illness. — 9 years ago, after much worry in business, glycosuria was 
discovered when patient applied for life insurance. His family physician pre- 
scribed diet and pronounced the condition only a transient glycosuria. Subse- 
quently life insurance was granted. He has had constant medical supervision 
and the tendency to glycosuria has steadily increased, so that during the past 2 
years he has never been sugar-free, and the amount has varied from 3 to 7 per 
cent. His weight has diminished from 195 to. 165 pounds. He can stUl do con- 
siderable work, but 'feels a decided impairment of strength and endurance. No 
polyphagia. Urine not more than 3 liters. He avoids sugar and most starches, 
but his diet includes oatmeal, two sUces of fraudulent gluten bread, fruits, vege- 
tables, and occasionally a potato. He was referred to the Institute by a com- 
petent general practitioner because both glycosuria and ketonuria were heavy on 
the diet stated. The physician was in the old-time dilemma of hesitating to 
increase glycosuria by adding carbohydrate, and fearing to increase acidosis by 
withdrawing carbohydrate. 

Physical Examination. — Height 172.5 cm. A well developed, adequately 
nourished, healthy appearing man. Teeth in good condition. Tonsils slightly 
enlarged. Liver edge 3 cm. below costal margin. Examination otherwise 
negative. 

Treatment. — ^The patient was kept for a week on an observation diet of 95 to 
120 gm. protein, 10 to 20 gm. carbohydrate, and 1800 to 2400 calories. The 
highest anunonia nitrogen excretion was 2.31 gm. There were no symptoms of 
danger or even discomfort. Fasting was begun on Dec. 5, first absolute, then (Dec. 
6 and 7) with alcohol up to 52.5 gm. This was followed by a low carbohydrate- 
free diet, but glycosuria promptly returned (Dec. 10 to 11) on about 50 gm. 
protein and 1600 calories. Ferric chloride reactions persisted, and the ammonia 



262 CHAPTER III 

excretion was practically as high as at the beginning. The case had been taken as 
a mild one. These signs indicated that notwithstanding the absence of striking 
symptoms, the real condition was by no means trivial and nothing but radical 
undernutrition could bring a satisfactory result. The patient was absolutely 
obedient and gave his full confidence, and a rigid program was therefore insti- 
tuted. With a view to combating acidosis, food was given chiefly in the form of 
alcohol, the highest intake being about 260 cc. whisky on certain days in Feb. 
The general plan of treatment is best seen from the graphic chart. Protein-fat 
diets were given on a few days, for example, Jan. IS to 17, but for the most part 
the diet consisted only of whisky with addition of carbohydrate from time to 
time up to the limit of tolerance. This hmit was very low. The giving of 40 to 
70 gm. carbohydrate in the form of green vegetables with no other food but 
whisky was sufficient to cause glycosuria on repeated occasions in Dec, Jan., 
and Feb. The maximum alcohol doses above mentioned, with the addition of 
these quantities of carbohydrate, failed to abolish the persistent, fairly heavy 
ferric chloride reactions. Also it was not possible to allow an adequate diet and 
await a later recovery of tolerance for clearing up acidosis, because the total food 
tolerance remained persistently low. For example, on Jan. 17 a carbohydrate- 
free diet of 89 gm. protein and 1790 calories gave rise to glycosuria lasting 2 days. 
Under such conditions it is generally necessary to master both the glycosuria and 
the acidosis before much real improvement of assimilation can be expected. At 
the end of Mar. and first of Apr. the patient's weight touched its lowest point, 
51.4 kg.; i.e., a loss of 19.2 kg. during 4 months of severe continuous under- 
nutrition. The patient had come to the hospital looking strong and robust. 
By this time he appeared thin and weak. His strength was definitely dimin- 
ished, and his general decline seemed so evident that only fuU confidence on his 
part and on the part of those conducting the treatment permitted the completion 
of the necessary program. But about this time the ferric chloride reactions grew 
steadily paler, until they were negative in certain urine specimens of each day and 
not more than traces in the other periods. Also a recovery of assimilation was 
evident, such that on Apr. S to 7 a diet of approximately 100 gm. protein, 20 gm. 
carbohydrate, 100 gm. alcohol, and 2200 calories was tolerated without glycosuria. 
Exercise had not been employed in the earUer treatment, because of uncertainty as 
to its effects in the presence of marked undernutrition and a persistent tendency 
to acidosis. It was now begun and rapidly increased up to the hmit of strength. 
The high calories in the later diets were permitted in proportion to the amount of 
physical labor performed. On Apr. 8 it appeared feasible to discontinue alcohol, 
and except for the fast-day on Apr. 11 it was never resumed. On Apr. 9 and 10 the 
diet was made approximately 100 gm. protein, 30 gm. carbohydrate, and 1500 cal- 
ories. This was increased rapidly to 2700 to 3000 calpries with the same protein 
and carbohydrate. A regular fast-day each week diminished the average intake 
to about 86 gm. protein and 2300 calories daily, or about 43 calories per kg. for 
the weight of approximately 54 kg. at that time. 



CASE RECORDS 263 

The patient, though thinner, now both felt and looked far better than at ad- 
mission. He was up to full strength in every way and able to carry on his regu- 
lar business and in addition take much exercise and recreation daily. He was 
discharged in this condition on May 8 to spend the summer in the country. He 
was instructed to report in 6 weeks and not to gain more than 2 pounds in this 
time. 

Subsequent History. — In the country he spent his days in walking, riding, swim- 
ming, tennis, and other exercise, buUding up strength while keeping weight 
within prescribed limits. In Aug. ferric chloride reactions ceased to appear. 
The urine never showed sugar except traces on rare occasions when he made 
unintentional mistakes in diet. He returned to resume his regular business in the 
city in Sept. 

On account of persistent hyperglycemia, exercise was increased, the patient 
preferring this to a reduction in diet. Daily exercise was taken in the form of 
horseback riding, athletic exercises under an instructor, swimming, and boxing. 
He also walks to business, an average of about 8 mUes daily, frequently walks 
20 or 30 miles on Sundays, and also plays tennis and squash three or four times a 
week. His business duties occupy about 5 hours a day, and in the remaining 
hours he has made a trained athlete of himself. Because hyperglycemia stiU 
persisted, on Dec. 17 the diet was made 130 gm. protein, SO gm. carbohydrate, 
and 2500 calories, this change representing particularly an increasd in carbo- 
hydrate and a diminution in total calories. At the same time he was allowed to 
increase his office work by 1 hour. On New Years day, 1916, the patient added 
a large baked potato to his diet without glycosuria, but was warned against a 
repetition. Traces of glycosuria appeared in subsequent months on rare occa- 
sions, and accordingly on July 10, 1916, the diet was diminished to 130 gm. 
protein, 40 gm. carbohydrate, and 2200 calories. In the entire time since then 
there was a trace of sugar in the urine only on 2 days. The weight at last report 
was 68.4 kg., in comparison with the 70.6 kg. at the time of first beginning treat- 
ment in hospital. The general strength and subjective condition are the best 
the patient ever enjoyed. 

Acidosis. — Though mostly shght, this was notably stubborn, and the mastery 
of it was one of the most difficult features of the treatment. The prolonged pro- 
gram of undernutrition, with alcohol short of intoxication and carbohydrate to the 
point of glycosuria, resulted in a slow decline of the ammonia to a normal level 
about the middle of Feb. There was a prompt rise with the addition of small 
quantities of protein and fat to the diet late in Feb. and early in Mar., followed 
by another slow decline. Also, in addition to the tenaciously persistent ferric 
chloride reaction, the CO2 capacity of the plasma indicated the same chronic ten- 
dency to acidosis. From the graphic curve it can be seen that the values were 
generally near the lower normal limit and frequently fell considerably below this. 
Sodium bicarbonate was used twice; namely, SO gm. on 1 day to check the par- 
ticularly marked fall of the plasma alkalinity at the close of Feb., and 30 gm. 



264 CHAPTER m 

daUy on Mar. 8 and 9. These doses gave immediate relief from slight symptoms 
of malaise of which the patient complained at this time. But obviously his fun- 
damental trouble was not lack of alkali, and the treatment had to be directed 
to the causes imderlying the state of acidosis. 

At the time of discharge from hospital the ammonia nitrogen excretion was stiU 
0.8 to 1.2 gm.; and some color was shown with ferric chloride in certain urine 
specimens every day, while specimens in other portions of the day were negative. 
As mentioned, the ferric chloride reactions became fully negative in Aug. and 
have remained so since. Acidosis has also remained absent by other tests. On 
July 25, 1916, the CO2 capacity of the plasma was 60.6 per cent, and it has since 
remained high. 

Exercise and Blood Sugar. — It seems probable from other experience that no 
harm would have been done and progress might have been hastened by using ex- 
ercise in this case from the outset. The improved assimilation of carbohydrate 
and other food might have aided in a quicker clearing up of acidosis. Exercise 
was carried to a higher point in this patient than in any other of the series. As 
stated, he has made a trained athlete of himself and has enjoyed the highest 
vigor and subjective health. In a general way it seemed evident that exercise 
improved his assimilation. Precise experiments concerning the effect of exercise 
upon his blood sugar were not performed. 

It will be noted in the graphic chart that the blood sugar in the latter part of 
Mar. was below 0.15 per cent and fell to normal. With the higher carbohydrate 
and higher total diet in Apr. it rose as high as 0.17 per cent, but came down, 
apparently as a result of exercise, to a nearly normal level at discharge. After 
leaving hospital the patient's weight gradually rose and the blood sugar likewise 
increased. On Oct. 6, with weight up to 60.9 kg., the sugar in whole blood was 
0.185 per cent, in plasma 0.208 per cent. It was at this point that a maximum of 
exercise was begun, the patient preferring this to a reduction of diet. Nevertheless 
on Oct. 18 the sugar in the whole blood was 0.192 per cent, in the plasma 0.208 
per cent, whUe the patient was feeling in splendid condition. On Oct. 25 the 
blood sugar was again 0.192 per cent and the plasma sugar 0.208 per cent; on Oct. 
28 the plasma sugar was 0.222 per cent; on Nov. 15 the blood sugar was 0.161 per 
cent, plasma sugar 0.222 per cent. Traces of glycosuria had formerly been cleared 
up on repeated occasions by exercise, but it seemed evident that the diet was too 
high, so that exercise could not lower the hjrperglycemia or entirely prevent re- 
currences of these traces of sugar. Accordingly the diet was modified on Dec. 
27 as above noted. On July 10, 1916, the blood sugar was 0.156 per cent, the 
plasma sugar 0.217 per cent. The weight as above mentioned was higher than 
before; namely, 68.4 kg. On July 25 the blood sugar was 0.143 per cent, the 
plasma sugar 0.169 per cent. On Aug. 2, 1916, the blood sugar was 0.167 per 
cent, the plasma" sugar 0.178 per cent. A reduction of body weight is the one 
means which may be expected to control the hyperglycemia. The chief value of 
exercise from the standpoint of permanent results probably consists in buming 



CASE RECORDS 



265 



up surplus calories and keeping down excess weight. Exercise has doubtless been 
somewhat overdone in this case. 

Nitrogen Loss. — In the prolonged period of almost protein-free diet, it is evi- 
dent that much protein must have been lost from the body. The nitrogen analy- 
ses of the urine are very incomplete. If the known points of the nitrogen output 
are joined to make a curve as shown in the graphic chart, a reckoning from such a 
curve win give a rough idea of the depletion of body nitrogen. The general 
undernutrition is evident from the following table: 



Total nitrogen output 

Protein intake 

Nitrogen " 

" deficit (output — intake) 

Alcohol calories in diet 

Food " " " 

Total " " " 



77 days. 




Per day 

(average) . 




511.32 


gm. 


6.61 


gm. 


1236.20 


It 


16.10 


{{ 


197.80 


tt 


2.50 


u 


313.52 


tt 


4.14 


tt 


28979 




376 




24284 




316 




53263 




692 





Alcohol. — Prolonged high dosage of alcohol in this patient was for the purpose 
of kpeping up strength by supplying calories and if possible aiding to diminish 
acidosis. According to clinical indications it was of value for the first purpose. 
There is no evidence that it had any value for the second purpose. If the thing 
were to be done over, less alcohol or none would be used. Better and quicker 
results could doubtless be obtained by a low protein diet, without fat, with vege- 
table periods interspersed. Body nitrogen and strength would be better con- 
served by the protein. Alcohol is probably injurious rather than beneficial as 
regards acidosis. 

Remarks. — ^The outstanding feature of this case is that a patient in seemingly 
good physical condition was subjected to over 3 months of continuous under- 
nutrition and brought into a thinner and seemingly worse condition as a thera- 
peutic measure on the basis of laboratory findings alone. The case was not 
mUd as imagined when the patient was admitted. It is believed, on the con- 
trary, that trouble was shortly impending. The condition confronted was an 
assimilation of carbohydrate or protein so low that glycosuria resulted from a 
very low intake, and a mild but very stubborn acidosis. An attempt to give any 
considerable quantities of protein and carbohydrate would have resulted in con- 
tinuous glycosuria. The use of any considerable quantities of fat would have in- 
creased or prolonged the acidosis. Accordingly the only escape lay in undernutri- 
tion until this dilemma could be broken. The undernutrition was therefore pushed 
to the necessary point without hesitation because of any clinical appearances. 
The result was successful as stated, and it is believed that a successful result 
could not have been attained on any program overtaxing the patient's tolerance 



266 CHAPTER ni 

on the side of either carbohydrate or fat. The ultimate outcome has been good 
from both the clinical and the laboratory standpoints. The persistent hyper- 
glycemia is the one unfavorable feature. Unless it diminishes in the natural 
course of improvement under present treatment, a reduction of body weight will 
have to be ordered; otherwise there may be downward progress and somebody 
may call it spontaneous. With simple precautions now, the situation promises 
a favorable outcome of an unexpectedly difficult case. 

CASE NO. 24. 

Male, married, age 44 yrs. American; manufacturer. Admitted Nov. 28, 
1914. 

Family History. — Father and mother still ahve. The former has glycosuria, 
discovered 4 years ago, but no other symptoms.' A paternal aunt died of cancer. 
A brother and a sister of the patient are well. Patient has been married 30 years. 
Wife had two miscarriages, then one chUd, who is ahve, aged 19. 

Past History.— Healthy hfe, spent in small town in Indiana. Measles and 
mumps in childhood. Neisser infection at 19. SyphUis denied. Rheumatism 
10 years ago; joints involved successively and very painful; night sweats; illness 
lasted about 6 weeks but was not severe enough to confine to bed. Occasional 
sore throats before and since this time. 8 years ago patient had indigestion, 
with pain after eating, pale feces, and yellowness of skin. This continued about 
a year and he lost 25 pounds weight, but finally recovered under forced feeding. 
No fever or sharp pain at any time. There is a discharge from the left ear 
dating from boyhood. Hearing is much impaired in this ear. No excesses in 
alcohol or food. For many years he smoked 6 to 10 cigars daily. Last Mar. 
he diminished his smoking to a minimum; has noticed no benefit. Normal 
weight is 165 pounds. 

Present Illness.— 7 years ago, on account of loss of weight, extra food was 
taken and considerable candy eaten. There was no special appetite, and no 
thirst or other symptoms, and the food and candy were taken merely with the 
idea of putting on weight. His eyesight then began to fail, and he consulted an 
ocuUst who examined the urine and diagnosed diabetes. A diet was later pre- 
scribed, and on this he regained some weight. Within a year, however, there 
was further loss of weight, and polyphagia, polydipsia, and polyuria were pres- 
ent. He then spent 10 days in a diabetic sanitarium, and became sugar-free for 
the first time in 10 months on carbohydrate-free diet with whisky and sodium 
bicarbonate. For the past 5 years he has made annual trips to this sanitarium, 
remaining for 10 days to 10 weeks at a time. During the past 3 or 4 years he 
has not become sugar-free on these trips. During the past year he was worn out 
by nerve strain attendant upon a defalcation and a lawsuit. On the last day 
of the trial he had to be carried to court on a cot to testify, and has been bed-fast 

'The father refused all dietary restrictions, and died of diabetes in Jan., 1919. 



CASE RECORDS 267 

for the 2 months since that time. He was brought to this Institute from Indiana 
with his physician in attendance, and had to be wheeled or carried. 

Physical Examination. — Height 173 cm. A well developed, extremely emaci- 
ated man, showing evidence of profound weakness but no acute distress. Teeth 
in good condition. Throat congested. Slight enlargement of lymph nodes in 
left axilla and groins. Knee jerks sluggish. Routine examination otherwise nega- 
tive. The most striking feature aside from the emaciation is a lemon yellow color 
of the skin, most pronounced on the face, but noticeable also over most of the 
body; the conjunctivae are bluish white and not jaundiced, and the urine is 
free from bile. The color suggests pernicious anemia. Blood examination 
showed hemoglobin 80 per cent, red cells 4,000,000, leucocytes 6,000, with normal 
differential count. Lipemia of heaviest degree present; plasma hke cream. Was- 
sermann negative. Urine free from albumin and casts. Blood pressure only 70 
systolic, diastolic doubtful at about SS. 

Treatment. — Because of the extreme weakness and the absence of threatening 
acidosis, the patient was given for 2 days a diet Hke that to which he had been 
accustomed; i.e., on Nov. 28 and 29 about 100 gm. protein, 20 to 30 gm. carbohy- 
drate, and 2000 to 2100 calories. On Nov. 29 he excreted 45 gm. sugar and 2.5 
gm. ammonia nitrogen; on Nov. 30 (the first fast-day), 20.5 gm. sugar and 2.78 
gm. ammonia nitrogen. Fasting was begun on Nov. 30, with some misgivings on 
account of weakness. Because of tendency to nausea only 30 gm. alcohol were 
given the first day, increased to 70 gm. by Dec. 5. Glycosuria was absent by 
Dec. 5, and the ammonia nitrogen had diminished to 0.88 gm. (total N output 
3.83 gm.). The ferric chloride reaction was much diminished but still well 
marked, and the blood plasma was still intensely lipemic. The patient's strength 
showed no dechne whatever on account of the fasting, and possibly a slight im- 
provement. He was able to sit up in bed to read, and could walk to the bath- 
room with assistance. The fasting was therefore prolonged through Dec. 6, 
making 6 days. On Dec. 7, one egg, 10 gm. butter, and 500 gm. thrice cooked 
vegetables were added to the whisky. This was increased daily, so that on Dec. 
10 the intake was 52 gm. protein and 1450 calories. On this diet a glycosuria 
of 9.9 gm. appeared. A fast-day with 100 cc. whisky on Dec. 12 failed to clear 
up the glycosuria. Only one egg and 20 gm. butter were added to the whisky 
on Dec. 13, yet glycosuria persisted. On Dec. 14, another fast-day with 140 
cc. whisky cleared up the sugar and the ferric chloride reactions. On Dec. 15, a 
diet of only 17 gm. protein and 600 calories (450 of which were alcohol) caused 
glycosuria of 2.61 gm., this sugar being doubtless partly attributable to the 1000 
gm. thrice cooked vegetables allowed for the sake of bulk. This glycosuria per- 
sisted under similar conditions on Dec. 16, so that a fast-day with 140 cc. whisky 
became necessary on Dec. 17. . Beginning Dec. 18, all vegetables were omitted 
in the attempt to build up strength. A diet was given on Dec. 18 and 19 of 52 
gm. protein in the form of eggs, 420 calories of alcohol, and olive oil to bring the 
total calories up to 2600. The ammonia excretion rose, and persistent traces of 
glycosuria appeared. The diet was sharply reduced, so that on Dec. 21 it con- 



268 CHAPTER III 

sisted of only two eggs and 130 cc. whisky. The eggs were increased until on 
Dec. 26 seven were given. Though such diets were frequently below 1000 cal- 
ories and composed largely of alcohol, traces of glycosuria remained persistent. 
It became established during this time that the patient could not tolerate even 
the carbohydrate of 200 gm. thrice boiled vegetables such as celery or Brussels 
sprouts, and the protein of six or seven eggs also sufficed to cause glycosuria. 
Under such circumstances the prospects for nourishing a patient already seri- 
ously weak seemed hopeless. But the notable feature was that the patient's 
strength and spirits continually improved during the time when he should theo- 
retically have been starving. He became able to sit up in a chair, but was con- 
fined to bed almost continuously under orders. 

On Jan. 5, 50 cc. whisky, 200 gm. thrice boiled celery, and 100 gm. thrice 
boiled asparagus were taken without glycosuria. On Jan. 6, meat and bacon were 
added, and the diet was 20 gm. protein, 600 gm. thrice boiled vegetables, and 480 
calories. This was tolerated, but on the next day (Jan. 7) 36 gm. protein and 
900 calories with only 400 gm. thrice boiled vegetables (celery, spinach, and Brus- 
sels sprouts) caused glycosuria. Diets of this sort or lower were continued, with 
almost continuous slight glycosuria. The carbohydrate intake shown by the 
graphic chart Jan. 21 to 28 was in the form of caramel, which was tolerated in 
quantities of IS to 30 gm. daily without glycosuria. Under these low diets the 
body weight gradually fell, while the strength slightly increased and the ferric 
chloride reactions became pale or negative. With the progressive improvement 
it became possible early in Feb. to raise the diet to approximately 68 gm. pro- 
tein and 1400 calories, 250 of these being alcohol calories. In the latter part of 
Feb. the intake could be markedly increased, and in Mar. and Apr. the diet ran 
as high as 80 to 90 gm. protein and 2500 calories (of which 250 were alcohol) 
and 200 to 300 gm. thrice cooked vegetables. With this there was a fast-day 
weekly. During Feb. the patient was allowed out of bed, and in Mar. he was 
encouraged to make trips from the hospital for exercise. On Mar. 12, he was 
able for the first time to walk a mile. Thereafter he took steadily increasing 
exercise, and high diets were allowed not only to build up strength but also to 
support muscular activity. Glycosuria was limited to bare traces demonstrable 
only in certain fractional specimens of certain days and not in the mixed 24 
hour urine. But at the beginning of Apr. a more definite glycosuria appeared, 
also the blood sugar on Apr. 3 was 0.27 per cent. Accordingly food was stopped, 
making the diet on this day less than 900 calories. On Apr. 4 only 130 cc. whisky 
were given, and on the following days only whisky and soup. After these 3 
days of practical fasting, the blood sugar was down to 0.1 per cent. 

Then on Apr. 7, 5 gm. carbohydrate were given in the form of green vege- 
tables, and these without other food were increased on the following days, until 
50 gm. carbohydrate were taken without glycosuria (Apr. 10). On Apr. 12, the 
high protein-fat diets with weekly fast-days were resumed, with resultant hyper- 
glycemia, so that on Apr. 28 the blood sugar was 0.31 per cent. Accordingly 4 



CASE RECORDS 269 

days of absolute fasting were imposed, followed by a carbohydrate tolerance test 
in regular form. The tolerance was found to be almost 100 gm. carbohydrate. 
Up to May 20 diets were given below 1500 calories, containing 10 to 15 gm. car- 
bohydrate. Then, because of glycosuria and hyperglycemia, carbohydrate was 
omitted, but resumed again in June. By this time the patient could tolerate a 
daily ration up to 80 gm. protein, 20 gm. carbohydrate, and 2000 calories, with 
an absolute fast-day each Sunday. He was dismissed on such a diet, with the 
carbohydrate diminished to 15 gm. The urine was normal, and the clinical 
condition, aside from the emaciation, was good. 

Acidosis. — The excretion of as much as 2.75 gm. ammonia nitrogen at first in- 
dicated a rather marked acidosis, but dangerous symptoms were never present. 
An intense ferric chloride reaction was present, and there was the usual odor of 
the breath, but no dyspnea. As shown in the graphic chart, t|he ammonia rap- 
idly fell during the initial fast. On Dec. 8 the ammonia nitrogen was 0.74 gm. 
and the ferric chloride reaction was negative. Protein-fat diet, together with 
the use of whisky, sent the ammonia nitrogen up to 1.68 gm. on Dec. 11. It 
then fell promptly when the diet was reduced, and beginning Dec. 18 rose still 
higher as the diet was made higher than before, reaching the summit on Dec. 21. 
It again fell with reduction of diet, and even on the large carbohydrate-free diets 
of Mar. and Apr. never returned to the former height. The ferric chloride reac- 
tion became consistently negative in the period Jan. IS to 28. Many of the 
traces indicated elsewhere were only tinges of color in individual fractions of the 
24 hour specimens. For the sake of improvement ia strength, the above men- 
tioned high diets of Mar. and Apr. were continued in spite of the well marked 
ferric chloride reactions which they produced, with the idea that as long as the 
tolerance was rising and the urine kept sugar-free, the mUd acidosis could be left 
for disposal in the future. The curve of the blood bicarbonate, beginning Jan. 24, 
also reveals the slight chronic acidosis. Alkali was seldom used. 15 gm. sodium 
bicarbonate were given on the day of admission; also, toward the close of the initial 
fast, 15 gm. on Dec. 2 and 3, and 5 gm. on Dec. 4, all as precautionary measures. 
On Feb. 19, 10 gm. bicarbonate left the urine slightly acid. On Feb. 20, 20 gm. 
turned the urine alkaline. Likewise the carbon dioxide capacity of the plasma 
rose within the lower normal limit on Feb. 20 for the first time. It was still 
approximately at this level on Feb. 22, following the fast-day of Feb. 21. But 
then, because of the high fat diet or merely loss of the administered alkali, it fell 
steeply to the lowest value yet observed; namely, 40 per cent on Feb. 24. It 
promptly rose agaui on Feb. 25 without the use of alkali, and the tendency now 
to remain closer to the normal level may be interpreted as one indication of the 
general improvement. The fasting and minimal diets Apr. 3 to 11 brought 
another sharp fall, but thereafter on Apr. 15 it rose still higher than before. 
Again the fasting of Apr. 29 to May 2 brought another sharp drop below normal, 
followed by a rising tendency; so that on a moderate total diet containing a small 
quantity of carbohydrate the blood alkalinity at the last determination on June 



270 CHAPTER in 

24 was fully normal and higher than at any point in the entire previous record. 
Correspondingly the ammonia output was within normal limits, and the ferric 
chloride reaction in the urine had become consistently negative. 

Alcohol. — ^Whisky was given in moderate quantities for the sake of keeping up 
strength. It seemed clearly beneficial for this purpose. The patient felt less 
well with larger doses, and it was never pushed to any high quantity. There is no 
evidence of any effect ia clearing up acidosis. After Apr. 7 alcohol was (as in 
all cases when possible) discontinued altogether. The clearing up of the acidosis 
progressed uniaterruptedly, so that the impression is created that the alcohol 
was without influence in this regard. 

Blood Sugar. — A solitary determination on Jan. 25 showed a strictly normal 
value of 0.1 per cent. No fiulher analyses were made until Apr. 1, when the 
level was 0.145 per cent. The diets had been high, and at this time were raised 
to the maximum; namely, almost 3000 calories on Apr. 2. The result was glyco- 
suria, with hjrperglycemia of 0.27 per cent on Apr. 3. The subsequent 3 days 
of fasting and alcohol brought the blood sugar down to 0.1 per cent on Apr. 6. 
On Apr. 8, with carbohydrate feeding, it rose promptly to 0.182 per cent without 
glycosuria. On the ensuing carbohydrate-free diet of 2200 to 2S00 calories it 
rose steadily higher, up to 0.312 per cent on Apr. 28. 4 days of fasting restored 
a normal value of 0.118 per cent in the plasma on May 3. It will be noticed 
that in these periods of feeding and fasting the rise and fall of the blood sugar 
and body weight were parallel. A small amoimt of carbohydrate in the diet 
from May 11 onward was in excess of the true tolerance, as indicated by the rising 
blood sugar, which reached 0.20 per cent on May 18; and though it still rose to 
0.232 per cent on May 22, the omission of carbohydrate and a fast-day on May 
23 brought a fall to 0.138 per cent on May 24. With restoration of carbohydrate 
in the diet the blood sugar again rose, reaching 0.2 per cent on Jime IS. In gen- 
eral, it is seen that the hyperglycemia is a more delicate index of the tolerance 
than the glycosuria. On the other hand, it is by no means a sole criterion of the 
condition or progress. The normal blood sugar of Jan. 25 was the result of 2 
months of semistarvation. At later periods the blood sugar was higher, though 
the patient's diabetes was definitely improved, in the sense that he could tolerate 
more of all classes of food and more easily remain free from both glycosuria and 
ketonuria. In other words, an identical diet would doubtless have caused greater 
hyperglycemia in Jan. than in June. The hyperglycemia at the time of discharge 
was the one noticeably abnormal feature in the condition, but, as the subsequent 
experience showed, it could be borne by such a patient without preventing the 
general tendency to improvement under treatment. 

Body Weight. — ^The patient, whose normal weight was 75 kg., entered weighing 
44.2 kg., i.e., 59 per cent of his normal weight, or a loss of 30.4 kg. During 
fasting his weight rose by water retention, the sodium bicarbonate of Dec. 2 and 
3 probably being responsible for the summit of the weight curve on Dec. 3. The 
rise of weight was accompanied by well marked edema of the ankles. The patient 



CASE EECOEDS 



271 



stated it had been present at former times to a still greater extent. With the 
continuous undernutrition there was a sUght progressive fall in weight, the lowest 
point being 39.8 kg. on Feb. S. Thereafter with the increased diets the weight 
steadily rose, so that the patient was discharged on June 28 at precisely his 
entrance weight of 44.2 kg. 

Nutrition. — ^The salient feature is the degree of undernutrition imposed upon a 
patient already extremely emaciated and weak. The patient himself had not 
expected to hve. Notwithstanding this state of weakness, he not only with- 
stood a 6 day fast successfully, but also bore 2 months of radical undernutrition 
thereafter. 

From Nov. 30 to Feb. 2 the following calculation can be made. 





65 days. 


Per day 
(average). 


Per day 
per kg.* 




1655.8 gm. 
264.9 " 
23362 
28249 
51611 


25.40 gm. 
4.07 " 
359.4 
434.6 
794.0 


5.80 gm. 
0.09 " 
8.00 


Total nitrogen in diet 

Alcohol calories 


Food " 


10.00 


Total " 


18.00 







* On 44 kg. weight. 

The case at first seemed hopeless, with the combination of emaciation and 
weakness on the one hand and inabUity to tolerate a living diet on the 
other. The extreme restrictions necessary for controlling the diabetes were 
rigidly carried out, and the unmistakable gain in strength along with loss of 
weight under these conditions was the most surprising feature. At dismissal, 
with the identical body weight as at entrance, the physical condition was trans- 
formed. The man had come as a helpless bedridden invahd supposedly at the 
point of death. At discharge he was stiU very thin, and strangers regarded him 
as having tuberculosis or cancer, but he was able to make the trip to his home 
unattended and carry his two heavy suitcases without assistance. 

Subsequent History. — ^The patient resumed his business duties and also took con- 
siderable daily exercise as instructed, chiefly in the form of walking. He remained 
free from glycosuria and other symptoms, with continuous improvement in 
strength and health, untU he committed a few minor indiscretions in diet, con- 
sisting only in the addition of a few eggs and vegetables beyond the prescribed 
quantity. Persistent glycosuria resulted, which did not stop on omitting aU 
carbohydrate or on the routuie fast-days. He reported his condition promptly 
and was advised to return to the hospital. 

Second Admission. — ^The patient returned Oct. 17, 1915, weighing 45.2 kg.; 
i.e., a gain of 1 kg. The glycosuria and ketonuria on his regular diet were both 
rather heavy. The ammonia nitrogen was up to 1.54 gm. The carbon dioxide 
capacity of the plasma was as low as 46 per cent, and the plasma sugar was 0.35 
per cent. But the physical strength was still as good as at discharge, and the 



272 CHAPTER in 

task of treatment was far easier than before. Blood pressure 102 systolic, 82 
diastolic. 

After 1 week of observation on the diet which had been tolerated at the former 
discharge, fasting was imposed Oct. 24 to 31. The urine was sugar-free on Oct. 
30. On Nov. 1, 10 gm. carbohydrate were given in the form of green vegetables, 
followed by the usual increase of 10 gm. daily, and definite glycosuria appeared 
with 40 gm. carbohydrate. This may be compared with the 100 gm. tolerance 
in the previous May and with the zero tolerance at the outset of treatment. 

Beguming Nov. 8, a diet of 75 gm. protein, 5 gm. carbohydrate, and 1800 
calories caused glycosuria. Therefore carbohydrate was omitted, and the protein 
diminished to 50 gm., and total calories to 1300. This diet represented approxi- 
mately 1.1 gm. protein and 30 calories per kg., but the weekly fast-days brought 
the average down to approximately 0.9 gm. protein and 26 calories per kg. — a 
low diet especially in view of the rather vigorous exercise which the patient was 
encouraged to take. Nevertheless, the blood sugar remained unduly high and 
traces of glycosuria were frequent. 

Beginning Nov. 25, an attempt was made to mcrease protein while keeping 
the total calories the same by subtracting an equivalent of fat. The protein was 
thus gradually raised to 110 gm. on Nov. 30, the calories remaining 1300. The 
blood sugar rose markedly, and glycosuria appeared with 100 gm. protein on 
Nov. 29. 

Beginning Dec. 12, radical undernutrition was maintained imtil Jan. 7 in 
the most favorable manner possible, namely by restriction or almost complete 
exclusion of fat. The protein was at first kept unchanged at SO gm. On Christ- 
mas day as a special indulgence, 85 gm. protein were granted to allow the patient 
to enjoy turkey. After Jan. 28 the regular protein allowance was 60 gm. Owing 
to exclusion of fat, the total calories were only 300 daily up to Dec. 17. For the 
week of Dec. 20 they were increased to 600 by addition of alcohol. By increase 
of protein and fat they were brought up to 1000 on Jan. 3 to 6. The most strik- 
ing effect of the exclusion of fat was not upon the ammonia but upon the blood 
sugar, which was brought well within the normal limits. Also the tolerance was 
improved, so that beginning Jan. 8 the patient was able to tolerate a diet of 70 
gm. protein, IS gm. carbohydrate, and 1900 calories. The body weight was 
down to 43.2 kg., or 1 kg. less than at the former discharge, but the strength 
and general condition were better than at any former time. The patient was 
discharged on Jan. 18 to resume his business in his home town. 

Acidosis.— As mentioned, the ammonia output and carbon dioxide capacity of 
the plasma indicated a slight acidosis on admission. The high point of the am- 
monia nitrogen at 2.5 gm. on Oct. 26 does not necessarily mean that the ammonia 
rose on fastmg. The only previous determinations had been on Oct. 17 to 18, 
and it is possible that toward the close of the week of feeding the ammonia was 
higher than on Oct. 26. After this date the ammonia fell sharply, and reached 
a still lower point with the carbohydrate tolerance test on Nov. 3. With protein- 



CASE RECORDS 273 

fat diet it again shot up to 2.5 gm. N on Nov. 11. On Nov. 15, following a 
fast-day, it was again found at the lower level of 0.7 gm., rising again with pro- 
tein-fat diet. But as this diet was only 1300 calories, the ammonia remained de- 
cidedly lower than it had been with 1800 calories. Thereafter the curve slopes 
gradually down to the normal output of 0.35 gm. at discharge. The ferric chlo- 
ride reactions were easily cleared up and remained negative. The carbon dioxide 
capacity rose with fasting to the lower normal limit on Oct. 30. With a slight 
fluctuation it came safely up within normal values with the carbohydrate tol- 
erance test on Nov. 5. With the 1800 calory diet composed chiefly of fat, it fell 
steeply below the lower normal level on Nov. 10. Thereafter it fluctuated above 
and below the lower normal limit. The highest value, namely 71.6 per cent, 
was shown on the fast-day of Dec. 12. At discharge it was exactly at the lower 
normal limit of 55 per cent. 

Blood Sugar. — ^At admission the plasma sugar was 0.35 per cent, and with con- 
tinuance of observation diet reached 0.43 per cent on Oct. 21, and 0.44 per cent 
on Oct. 22. It fell sharply on fasting, so that on the second fast-day (Oct. 25) 
it was down to 0.17 per cent. The succeeding fluctuations are not explained. 
The behavior for several days is so bizarre that the accuracy of some analyses is 
called into question. But on Oct. 29, the day when glycosuria ceased, the 
plasma sugar had fallen to 0.23 per cent. With the carbohydrate tolerance test 
it rose to 0.325 per cent on Nov. 4. On Nov. 8, following the fast-day of Nov. 7, 
it was down to 0.2 per cent. The diiet of 1800 calories caused a rise to 0.44 per 
cent on Nov. 11. Thereafter, with the diet of 1300 calories, it wiU be seen that 
the sugar tended to be up during the week and down on the morning after the 
weekly fast-day, but hyperglycemia was continuous. The rigorous undernu- 
trition beginning Dec. 12 was what definitely brought the blood sugar down 
within normal limits. On the hberal diet with 15 gm. carbohydrate at discharge, ' 
hyperglycemia again resulted to the extent of 0.16 per cent plasma sugar. This 
was the one unfavorable feature at discharge. 

Exercise. — Beginning Nov. 11, the patient was exercised daily to the point of 
exhaustion, being required to walk up and down 8 flights of stairs 6 times daily, 
walk 3 or 4 miles, and toss a 6 pound medicine ball for half an hour daily. With 
this amount of labor the diet of 1300 calories was definite undernutrition, yet 
neither the body weight nor the blood sugar diminished very perceptibly. The 
clinical condition was rather unfavorably affected, however, and the patient was 
tired and exhausted from the prolonged exertions. Therefore, beginning Dec. 12, 
he was kept in bed during the period of marked undernutrition, and gained in 
well-being by reason of the rest. With the higher diets which began in Jan. 
he was allowed to take moderate exercise, and was advised to continue this at 
home. - 

Subsequent History. — ^The patient remained at home from Jan. 18, 1916, to 
June 25, 1917, and during this time missed only 6 days from his regular busi- 
ness, in consequence of slight additions to the diet, or on two occasions because 



274 CHAPTER m 

of colds. The weight was up to 48.1 kg. One of the colds mentioned then caused 
a setback requiring slight reduction of diet, so that during the summer the 
weight was approximately 46 kg. On Jan. 13, 1917, at the patient's request, 
he was allowed to diminish his diet from 1900 to 1500 calories, which he said 
satisfied him, and on this basis he omitted the weekly fast-days. On May 31, 
1917, a telegram was received from the patient stating that he had yielded to a 
holiday temptation to eat strawberry shortcake and pie, and was showing heavy 
glycosuria in consequence. He was instructed to fast himself sugar-free, and 
did so successfully. On June 13, he accidentally increased his diet by 300 calories, 
and showed a trace of sugar in consequence. 

Third Admission. — On June 25, he appeared unexpectedly at the hospital, 
stating that he had decided to travel for a change, and had dropped in to report, 
and to stay for examination if desired, especially as he was now finding trouble in 
remaining sugar-free after his recent indiscretions. The weight was 45.5 kg. 
Although slight glycosuria and ketonuria were found present, the condition was 
now very simple from the therapeutic standpoint, and the opportunity was em- 
ployed to carry out a test of the effect of fat feeding, as described in Chapter VI. 

Remarks. — The heavy Upemia which was such a striking feature of this case at 
the outset would have been an interesting feature to study chemically if 
circumstances had permitted. Presumably it was responsible for the remark- 
able yellow color of the patient, but this color persisted with Uttle diminution 
long after the blood plasma had become entirely clear. This color of the skin 
was very well marked at the second admission. By the third admission it had 
almost entirely disappeared and the complexion had begun to look normal. 

Also, though the weight was only 1.3 kg. more than at the original admis- 
sion, the face and bearing were different. The patient was stiU excessively 
thin, but with the change in facial expression, complexion, and energy of move- 
ment, strangers no longer looked upon him as a sick man, and he behaved in all 
respects like a normal person. The outcome is therefore a satisfactory one un- 
der the circumstances. The diabetes seems to be under control, and any mani- 
festations appearing can in each instance be cleared up more easily and quickly 
than on former occasions — one indication of favorable progress. The diabetes 
was genuinely severe, as demonstrated by the prolonged mtolerance of food and 
by the enture history. The heavy hpemia may probably be included among the 
symptoms of severity. Death must have resulted within a brief period in the 
absence of radical treatment. The ultunate prognosis in a case at this age is 
generally better than in younger persons, and the tendency to improvement 
seems more permanent and genuine. 

This patient furnishes another example of the absence of any perceptible 
spontaneous aggravation in a very severe case of diabetes under observation for 
2i years; but the possibility of downward progress due .to chronic pancreatitis may 
yet have to be considered. The patient describes himself as feeling better than 
for many years past. He carries on his work successfully and enjoys life. Fur- 



CASE RECORDS 275 

thermore, he has had no more attacks of cold and grippe than at periods before 
his diabetes, and no greater difficulty in recovering from them. Notwithstanding 
the still low tolerance, the outlook at the present time appears favorable for some 
time to come. 

CASE NO. 25. 

Female, married, age SO yrs. Austrian Jew; housewife. Admitted Nov. 28, 
1914. 

Family History. — Parents lived to old age. Four brothers and two sisters are 
well. No heritable disease in family. Patient has been married 28 years. Had 
six children and later three miscarriages. One child died of diphtheria, another 
in an accident; the other four are well, aged 13 to 26 years. 

Past History. — ^Healthy life. Patient came to United States from Austria at 
age of 28 and has lived in fairly hygienic surroundings. Erysipelas, in 1912 
and again in Jan., 1914, was practically the only infection. Venereal disease 
denied, although 3 years ago a general eruption is said to have appeared over the 
whole body and disappeared after a few days. 8 or 9 years ago, left-sided hemi- 
plegia occurred suddenly and improved gradually within 6 months. A second 
stroke occurred in Jan., 1914. Edema of ankles has been noticed during past 2 
years. Habits have been regular. No alcohol or other special indulgence. 

Present Illness. — 3 years ago a routine urine examination revealed sugar. 
Since then one test every month has always shown sugar but never acetone. For 
2 years past there has been dyspnea and palpitation on slight exertion, so that 
she has been practically confined to her house. Dyspnea also has frequently 
made her unable to sleep lying down at night, so that she has had to stay in a 
chair. No polyphagia, polydipsia, or polyuria. She has been on a lax anti- 
diabetic diet of protein, fat, and green vegetables unrestricted in quantity, and 
two roUs and a slice of bread daily. Weight 3 years ago 211 poimds, now 186 
pounds. 1 week ago the patient went to a hospital clinic, and was ordered to 
stop carbohydrate. Thereafter she began steadily to feel worse and has shown 
a progressively increasing stupor during the past few days, with nausea which 
has led to vomiting during the past 2 days. 

Physical Examination. — A large framed, obese woman lying in bed in a stu- 
porous condition and irrational when roused. The odor of the breath is partly 
sweetish, partly foul. Some dyspnea is present, but seems of a panting and ner- 
vous type rather than Kussmaul air-hunger. The face is sHghtly edematous and 
pits on pressure. Exophthalmos and apparent photophobia. Pupils react to 
light and accommodation. No jaundice. Pyorrhea and receding gums. Tonsils 
slightly enlarged. Signs of slight left-sided paresis. Thyroid lobes hard and 
definitely palpable; isthmus not felt. Lymph nodes not enlarged. Some bron- 
chitis and emphysema. Cardiac dulness extends 4 cm. to right of midstemal 
line and 13 cm. to left in fifth interspace. Soft systoHc blowing murmur at apex. 
Aortic second sound markedly accentuated. Walls of radial arteries not pal- 
pable. Abdomen obese and flaccid, negative to examination. Knee and Achilles 



CASE RECORDS 277 

On Dec. 9, this was increased to two eggs and 20 gm. butter; and though no 
vegetables or other sources of carbohydrate were given, a trace of glycosuria 
appeared, and continued when one egg was given on Dec. 10 and two eggs on 
the subsequent days. The protein intake ranged from 15 to 46 gm. and the 
total calories averaged well below 1000, even including alcohol, until on Dec. 
17 and 18 a diet of eggs and olive oil was given, without vegetables or whisky, rep- 
resenting 44 to SO gm. protein and 1900 to 2000 calories. Such diets sufficed to 
maintain a continuous glycosuria. This cleared up when nothing but two eggs 
was given on Dec. 20. But on Dec. 21, the feeding of only 80 gm. asparagus, 
containing 2.2 gm. carbohydrate, caused a trace of glycosuria. To clear this up 
3 fast-days with whisky were necessary, on Dec. 24 to 26. Then, on Dec. 27, 
the feeding of two eggs and 500 gm. thrice boiled vegetables brought back a 
decided trace of glycosuria. After omission of all vegetables, the frequent traces 
of glycosuria still continued on low diets Umited to eggs, olive oU, soup, and 
coffee, none of these diets containing more than 52 gm. protein and 1300 to 1950 
calories. The subsequent treatment represented a continuance of such under- 
nutrition. The principle was adopted of giving protein to conserve body nitro- 
gen and alcohol to assist weakness, while keeping fat and calories at a very low 
figure and compelling the patient to burn off her body fat. 

She remained almost without appetite, and on Feb. 4 mentioned being hungry 
for the first time. The ferric chloride reaction was much diminished and the 
occasional traces of sugar were only very faint reactions in fractional specimens 
on certain days. The patient was desirous of continuing treatment at home, and 
as all immediate danger was over and the one necessity was merely a continuance 
of undernutrition, she was allowed to go out on a diet of 1250 calories, 350 of which 
were alcohol. She was instructed to take a fast-day whenever sugar appeared and 
once every 2 weeks if it did not appear. She was also warned against constipa- 
tion and was encouraged to take exercise. At the time of discharge she was be- 
ginning to take short walks, which tired her considerably. Aside from the 
weakness, symptoms were absent and she felt well. 

Second Admission. — Feb. 11, 1915. The patient was readmitted 5 days after 
discharge. She had followed her diet but had had no bowel movement during 
this time. The former symptoms recurred in milder form, and she was drowsy and 
vomiting occasionally when received. The glycosuria was 0.6 per cent, and the 
ferric chloride reaction was heavier than at discharge. A low ammonia value 
was found on Feb. 13 after 3 days of fasting. There was no albuminuria, but the 
face and ankles were again puffy and pitted on pressure. Blood pressure 170 
systolic, 110 diastolic. 30 gm. sodium bicarbonate may have played a part in 
the edema. The treatment was carried out on the same lines as before, the 
most important feature being the purgation with 2 gm. compound jalap powder 
daUy, which yielded the same enormous stools as before. The first 12 days in 
hospital, up to Feb. 23, represented almost continuous fasting. 200 calories of 
alcohol were given almost daily during this entire period in hospital. The acute 



278 CHAPTER ni 

sj^nptoms passed off easUy. The food tolerance was obviously higher than be- 
fore, and a more liberal diet was gradually built up, finally reaching 83 gm. pro- 
tein and 2000 calories at the time of discharge on Mar. 25. Traces of glycosuria 
were frequent but easily controDed. Albuminuria was constantly present after 
the initial days. The blood pressure on Feb. 16 was 205 systolic, 130 diastolic; 
on Feb. 20, 185 systoKc, 140 diastolic. The patient was feeling stronger and in 
better condition in aU respects than at the former discharge. The diet pre- 
scribed to be followed at home was carbohydrate-free, containing 100 gm. pro- 
tern (1.5 gm. per kg.) and 1500 to 1750 calories (23 to 26 calories per kg.). It 
was considered probable that she could remain free from glycosuria on this diet, 
and if so the shght persisting ketonuria would gradually take care of itself. 

Subsequent History. — Reports showed that the patient remained sugar-free 
and continued to gain in strength and well-being at home. On May 21, her son 
telephoned that she had had some sort of stroke during the night and an ambu- 
lance surgeon had diagnosed pulmonary edema. Her death occurred the same 
day, and the certificate of the coroner's physician assigned chronic nephritis as 
the cause. There was no sugar in the urine at any time. 

Acidosis. — The acidosis was never quantitatively high, and the coma was 
atypical in character. There was the familiar history of onset shortly after 
exclusion of carbohydrate from the diet, but constipation seemed to be a more 
important factor. More complete analyses of blood and urine would have been 
valuable had they been possible at this time. Along with the general food in- 
tolerance, the ammonia nitrogen was slow in reaching normal limits, but at the 
first discharge was down to about 0.56 gm. At the second admission the figure 
0.28 gm. ammonia nitrogen was obtained after 3 days of fasting; there might weU 
have been a much higher ammonia earlier in the attack. Such a possibility is 
strengthened by the rise to almost 2 gm. ammonia nitrogen with the diet of only 
1100 calories on Feb. 26. The ferric chloride reaction became pale toward the 
close of each stay in hospital, and accordingly no further attention was paid to 
it, since with continuance of undernutrition and freedom from glycosuria it was 
certain to become negative. 

Estimations of the carbon dioxide capacity of the plasma were made begin- 
ning Feb. 23, and confirmed the tendency to chronic acidosis. Inasmuch as so- 
dium bicarbonate had been used rather liberally in the opening days of each 
hospital period and had presiamably raised the blood alkalinity, there is some 
ground for supposing that such analyses if made during the stuporous attacks 
would have indicated a true acidosis coma. Subsequently, in the absence of 
bicarbonate, the carbon dioxide capacity of the plasma in Feb. and Mar. ranged 
between 45 and 53 per cent. There is no evidence that alkali dosage would 
have altered the subjective condition, which was good; and the fundamental acido- 
sis process could be influenced only by continuance of the undernutrition pro- 
gram as adopted, whereas the giving of alkaU would only have masked the lab- 
oratory indications. 



CASE RECORDS 



279 



Blood Sugar. — Only one determination was made. This was 0.118 per cent 
before breakfast on Mar. 22. There is no evidence of a renal glycosuria, but on 
the other hand a continuous h)Tperglycemia seems excluded, notwithstanding 
both diabetes and nephritis. 

Undernutrition. — During the initial fast, Nov. 29 to Dec. 7, inclusive, the 
patient lost 94.3 gm. nitrogen in the urine. Dec. 8 to 11 the ingestion of 7.5 to 
15 gm. protein daily left the nitrogen output at its minimal fasting level of about 
8 gm. daily. The degree of undernutrition in the first period in hospital is shown 
by the following calculations: 



Total nitrogen output 

Protein intake 

Nitrogen " (protein -^ 6.25). 
" deficit (output— intake) 



13 days. 



127.19 gm. 
46.70 " 
10.35 " 
116.84 " 



Per day 
(average). 



9,78 
2.60 
0.79 
8.99 





70 days. 


Per day 
(average). 


Alcohol calories . .... 


18518 
25701 
54219 


264.5 


Food " 


495 7 


Total " 


760 2 







Owing to the clinical condition it was not feasible to weigh the patient uritU 
Dec. 6, when the weight was 76 kg. The obesity was diminished as rapidly as 
feasible by undernutrition, while the body nitrogen was protected as far as pos- 
sible by allowing protein in quantities just short of producing any considerable 
glycosuria. Fat was the element which was mainly eliminated from the diet, 
and general undernutrition and the burning off of body fat was regarded as the 
most important therapeutic measure. At the first discharge the weight was 68.4 
kg., and at the second admission and discharge respectively it was approximately 
66 kg.; i.e., 10 kg. below the first weight. Strength, well-being, and food toler- 
ance had risen in proportion to the fall in weight. 

Remarks. — The importance of emptying the bowels when there is impending 
coma, especially in certain cases, has been pointed out by former writers. In 
this instance it seemed the most important therapeutic measure. Though there 
were chemical indications of acidosis as above noted, the urine was easily 
made alkaline and the actual quantity of acid formed was evidently not great. 
A feature of therapeutic interest is the fact that a very obese patient already 
suffering from acidosis with nausea and vomiting came through safely with 
simple fasting. There is no evidence of any specific value of the alcohol used. 
The danger of increased acidosis from fasting in patients of this type is obviously 
to be borne in mind; but a coma which comes on with feeding can generally be 
treated by fasting. The reduction of the excessive body weight was beneficial 



280 CHAPTER ni 

from every standpoint. Judging by the threatened coma and subsequent almost 
complete intolerance of food, the case might be called extremely severe, but with 
mere continuance of undernutrition sufficient to bring the excessive weight 
down to normal or slightly below the average normal, the condition would almost 
certainly have stood revealed in its true light as one of fairly mUd diabetes. For 
this reason, with falling body weight and rising general health, the traces of 
glycosuria and ketonuria were ignored to an extent never ventured in younger 
patients. Also this patient's nephritis was far more dangerous to her than her 
diabetes. The existence of nephritis in no way interfered with the treatment of 
the diabetes. Though the blood pressure diminished as the ordinary conse- 
quence of hospital care, there is no indication that the nephritis was improved 
by the diabetic treatment. It so happened that death came early from some 
embolic or other accident, but the case nevertheless Ulustrates the benefit of 
proper treatment of diabetes even in the presence of complicating conditions. 

CASE NO. 26. 

Female, age 14 yrs. American; schoolgirl. Admitted Dec. 7, 1914. 

Family History. — No diabetes in family. Mother's mother died of cancer, 
and mother's grandmother of "dropsy." Several more remote relatives died of 
tuberculosis. Patient's father is healthy, the mother nervous but fairly strong. 
There have been no other children and no miscarriages. 

Fast History. — Girl has been healthy though rather nervous. Measles at 3, 
chicken-pox at 4, mild whooping-cough at 5. She began school at 6th year, was 
bright and studious but not overworked. Ate large quantities of candy. Al- 
ways constipated. Fairly normal menstruation began at 12. For about 2 years 
before the present illness there was frequent twitching of face, limbs, and trunk 
during sleep. No such movements when awake. 

Present Illness. — In Feb., 1913, the patient had an attack of vomiting after 
eating heavily, and for a few days was nervous and without appetite. During 
the following 3 weeks polyphagia, polydipsia, and polyuria were noted, also 
weariness and sleepiness. Strength then failed progressively until she became 
too weak to dress herself. A physician consulted in Mar. diagnosed diabetes and 
prescribed carbohydrate-free diet. On this the patient remained sugar-free until 
June, but lost weight even though bread and potatoes were gradually added to 
diet. Glycosuria then reappeared, but remained absent from June to Dec. on 
carbohydrate-free diet. It then became persistent, and a trip was made to 
consult a specialist, who placed the patient in a hospital for 2 weeks and allowed 
only small quantities of carbohydrate-free food. Glycosuria ceased but keto- 
nuria persisted, and all symptoms recurred promptly on returning home. The 
family physician then allowed an abundance of carbohydrate. The subsequent 
symptoms have been the usual loss of weight and strength, and falling out of much 
of the hair. Menstruation ceased with the first period after the onset of diabetes. 



CASE RECORDS 281 

Physkal Examination. — A tall, emaciated, nervous appearing girl, without 
acute distress. Teeth in good condition. Tonsils not enlarged. No lymph 
node enlargements. Skin dry. General physical examination negative. Right 
knee jerk present, left not obtained. Achilles jerks lively. Blood pressure 105 
systolic, 70 diastolic. 

Treatment. — ^The glycosuria for 16 hours following admission was 44.5 gm. 
On Dec. 8 to 10, under an observation diet of 30 to 65 gm. protein, 3 to 10 gm. 
carbohydrate, and 900 to 1300 calories, the urine contained 6.8 to 14.3 gm. sugar 
and showed heavy ferric chloride reactions. Fasting was begun Dec. 11, with 
200 calories of alcohol daily. Glycosuria was absent in 24 hours. 140 gm. thrice 
cooked vegetables were allowed on Dec. 13, 5 gm. carbohydrate in the form of 
green vegetables on Dec. 14, and 9 gm. carbohydrate on Dec. 15. A trace of 
glycosuria appeared. Nevertheless the vegetables were increased, up to 44 gm. 
carbohydrate on Dec. 17, then diminished while two or three eggs were added. 
With this continuance of undernutrition the trace of sugar cleared up. On Dec. 
26 a diet of 51 gm. protein, 9 gm. fat, and 1200 calories caused another trace of 
glycosuria, which cleared up with the fast-day of Dec. 27. Alcohol was discon- 
tinued on Jan. 9. It was still given on fast-days to the extent of 200 calories, 
up to Feb. 21. In early Jan., diets of approximately 40 gm. protein, 6 gm. car- 
bohydrate, and 1000 calories twice caused slight glycosuria, which later cleared 
up, and at the end of the month a diet as high as -80 gm. protein, 16 gm. 
carbohydrate, and 1700 calories was borne without glycosuria. An attempt 
on Jan. 30 and 31 to raise the carbohydrate to 25 gm. resulted in gly- 
cosuria, checked by the routine fast-day of Feb. 1. In the succeeding week the 
diet was further increased until on Feb. 5 to 6 glycosuria resulted from 90 gm. 
protein, 30 to 40 gm. carbohydrate, and 2400 calories. Thereafter still higher 
diets were tolerated, but on Feb. 27 glycosuria was produced by 84 gm. pro- 
tein, 50 gm. carbohydrate, and 3000 calories. Not only the laboratory findings 
but also the weakness and nervousness which were the essential complaints were 
improved. Also, on admission there had been a marked albuminuria with 
casts, but albumin gradually diminished to a trace and casts were absent. The 
patient was discharged on Mar. 6, 1915, on a diet of 25 gm. carbohydrate, 75 
to 80 gm. protein (2.5 gm. per kg.), and 2400 calories (almost 80 per kg.). The 
regular weekly fast-days reduced the average to approximately 64 gm. protein 
and 2100 calories. The prescribed diet was thus below what she had proved 
able to tolerate. 

Acidosis. — This was at no time threatening. The ferric chloride reaction 
diminished as usual and became negative with the low diets of mid- January. 
It will then be noted that increase of the total diet brought back well marked 
ferric chloride reactions, even though carbohydrate was decidedly increased at 
the same time. 

Body Weight. — ^This was 31.2 kg. at admission. The undernutrition treat- 
ment brought it down to its lowest point of 27.2 kg. on Jan. 26. Thereafter the 



282 CHAPTER rn 

higher diets produced a rise in weight, so that at discharge it was 30.7 kg.; i.e., 
0.5 kg. less than at admission. 

Subsequent History.— The diet was faithfully followed. A few traces of glyco- 
suria required a slight diminution of the carbohydrate allowance. On one occa- 
sion a trace of glycosuria followed excitement due to having seen a woman run 
over by a street car. The physical and psychic conditions remained good and 
the patient enjoyed hfe and kept herself interested in various occupations not 
involving exertion. Nevertheless, she tended to lose slightly in weight instead of 
gaining. Menstruation did not return, but none of the former symptoms of 
diabetes was present. 

Second Admission. — Oct. 4, 1915, the patient returned to the hospital by 
arrangement, for purposes of observation and for testing the effect of exercise. 
Height 156.2 cm. Weight 28.8 kg. 

The urine was stiU sugar-free, but showed a trace of ferric chloride which 
disappeared with a single fast-day on Oct. 5. A tolerance test was then be- 
gun in routine manner with 10 gm. carbohydrate in the form of green vege- 
tables on Oct. 6. A trace of glycosuria appeared with 130 gm. carbohydrate on 
Oct. 19, and persisted with the same intake the next day and with increased in- 
take on the following days, notwithstanding the introduction of exercise at this 
point in the attempt to raise tolerance. After the clearing up of glycosuria by a 
sharp reduction of food on Oct. 24 to 25, a diet was gradually buUt up, with the 
usual weekly fast-days. In the week of Nov. 22, a ration of 55 gm. protein, 15 
gm. carbohydrate, and 2200 calories was tolerated without glycosuria, but with 
ketonuria. With the same protein and carbohydrate, an increase of fat to 2400 
calories in the following week brought on well marked continuous glycosuria, 
and the damage thus done resulted in a continuance of glycosuria and ketonuria, 
notwithstanding a sharp reduction of diet in the succeeding week (Dec. 6 to 11). 
Low nutrition beginning Dec. 12 was continued throughout the remainder of the 
stay in hospital. From Dec. 15 to Jan. 22, the protein was kept at 60 gm. daily. 
The calories at first were 1200, but beginning Jan. 3 were diminished to 850. 
Though all carbohydrate was omitted at the same time, this diminution in total 
calories brought a complete clearing up of the ferric chloride reaction. Begin- 
ning Jan. 24 another carbohydrate tolerance test was made. The assimilation 
was found to be 140 gm., a gain of 20 gm. over the previous test. The patient 
was discharged Feb. 26 on a diet of 30 gm. carbohydrate, 60 gm. protein (2.26 
gm. per kg.), and 1000 calories (nearly 36 calories per kg.). This was reduced 
one-seventh as usual by the regular fast-days, making the average daily intake 
approximately 1.9 gm. protein and 33 calories per kg. 

Acidosis. — The most striking feature is that well marked ferric chloride reac- 
tions were produced by high calory diets in every instance, irrespective of whether 
these diets contained carbohydrate. On lower diets suited to the patient's actual 
tolerance there has been no difficulty in keeping this test continuously negative. 
The ammonia excretion is also kept at a low level. The carbon dioxide capacity 



CASE RECORDS 283 

of the plasma tended to remain near or below the lower normal limit, but was 
within normal limits at the time of discharge. 

Blood Sugar. — Though this must have been high with the glycosuria resulting 
from the carbohydrate test of Oct., yet, as usual when hyperglycemia is pro- 
duced only by carbohydrate, it fell quickly, for on Oct. 25, after 2 days of low 
diet, it was down to 0.13 per cent. It promptly rose to 0.26 per cent in the 
plasma on the next day with continuance of a diet of 1200 calories and 15 gm. 
carbohydrate. On the morning of Nov. 1, following the fast-day of Oct. 31, it 
was down to the former approximately normal level. The curve ran similarly 
through Nov., with hs^perglycemia on feeding and lower values following fast- 
days, but with a general upward tendency. The diet up to 2400 calories, ending 
Dec. 4, had produced such injury that the reduction to 1500 calories did not 
prevent the occurrence of the highest blood sugars of the series; e.g., 0.32 on 
Dec. 9 and 0.29 on Dec. 11, with glycosuria. This was one of the reasons for the 
ensumg sharp reduction of diet. After 2 days of fasting on Dec. 12 and 13, the 
sugar in the plasma on the morning of Dec. 14 was down to 0.155 per cent, and 
in the whole blood down to 0.125 per cent. Thereafter the curve ran nearly 
within normal limits, except for the sharp terminal rise on Feb. 25 to 0.224 per 
cent. This occurred on 40 gm. carbohydrate, and the patient was sent home 
with only 30 gm. carbohydrate in the diet. . 

Body Weight. — At the second admission this was 2 kg. less than at the pre- 
vious discharge, and at the second discharge it had been brought down still 
lower. The net result of treatment from the first admission to the second dis- 
charge was a reduction of weight by 4.9 kg. At home the patient's weight has 
been constantly reported as approximately 60 pounds; i.e., about 27 kg., or 4 
kg. less than at her first admission. There has been no appreciable growth in 
height, but the patient was already almost as tall as her mother. She is notice- 
ably emaciated, but the graphic chart well illustrates that every gain of weight 
brought on glycosuria and acidosis. In order to Uve, the patient must keep her 
weight down. It is not only inadvisable but impossible to force the weight up, 
for any diet exceeding her tolerance as respects food and weight wiU quickly 
bring on active diabetic symptoms, which of themselves would lead to loss of 
weight. 

Exercise. — The second period in hospital was devoted largely to a clinical test 
of exercise in this patient. During the carbohydrate tolerance test in Oct. she 
was kept at rest until the first trace of glycosuria appeared. She was then ex- 
ercised to the limit of her strength, chiefly by climbing stairs and walking, also 
by roller-skating and tossing the medicine ball. The glycosuria did not cease, 
and no gain in tolerance could be demonstrated. Subsequently high diets were 
given, as stated, from the latter part of Oct. to the forepart of Dec; and the 
patient, who was moderately strong, was exercised regularly to her utmost ca- 
pacity in the attempt to bum off the surplus calories. The low plasma bicarbon- 
ate during this time is doubtless due in part to exercise. It proved impossible to 



284 CHAPTER in 

prevent hyperglycemia and finally glycosuria by this means, and the ferric 
chloride reaction became positive when exercise was thus taken to bum up the 
fat, though on lower fat intake it was negative even without exercise. Accord- 
ingly in Dec. the diet was reduced as above mentioned. Exercise was still 
continued. 

From Dec. 12, 1915, to Jan. 23, 1916, three influences were present, namely, 
carbohydrate abstinence, undernutrition, and hard muscular exercise. Never- 
theless, the absence of any noteworthy acidosis is demonstrated by all tests. 
The rise of 20 gm. in tolerance shown by the carbohydrate test in Feb. is merely 
what might be expected from the undernutrition treatment, and there is no 
indication that the 4 months of hard systematic exercise had served specifically to 
increase tolerance. 

Subsequent History. — ^At the time of discharge the patient was advised to dis- 
continue severe exercise and take only as much as she could enjoy. She has 
foimd pleasure in spending much of her time in walking, bicycling, and various 
forms of active play. What has actually been accomplished by exercise is a 
decided gain in strength, general health, and happiness. The change, as com- 
pared with the first admission when she was kept nearly at rest, is evident at a 
glance, and friends complimented her on her improved color and appearance. 
Nervousness and worry are also controlled, and she is enabled to derive some real 
enjoyment from life. 

Glycosuria has remained absent except for rare traces due to unintentional 
excesses; e.g., traces resulted from the use of cream cheese or sugar cured ham. 
By June 19 she had lost three quarters of a poxmd in weight, but this was slightly 
more than regained by Sept. In the fall she undertook light school work. In 
Nov. and Dec. she had two colds and showed traces of sugar several times in 
consequence, so that carbohydrate had to be entirely eliminated from the diet on 
some occasions. In Apr., 1917, the patient reported having finished the first year 
of high school and having easily obtained the highest mark in every subject. 
Her diet has been modified to consist of 40 gm. protein, 10 gm. carbohydrate, and 
1000 calories. She keeps herself sugar-free without difficulty and knows how to 
treat herself if accidental causes bring on traces of glycosuria. 

Remarks. — This patient, when received, presented a case of juvenile diabetes 
of 2 years standing and considerable severity. The subsequent treatment illus- 
trates especially two points. One is the effect of exercise. The case was of 
such severity that the deficiency of the pancreas could not be balanced to any 
appreciable extent by improved function and activity of the muscles. Accordingly 
the carbohydrate tolerance was not perceptibly improved, but the general health 
was greatly benefited. Second is the question of growth and nutrition. Here 
the clinical experiment was performed of taking this patient, clearing up her 
condition radically by undernutrition, so that about the middle of Jan., 1915, 
she was entirely free from both glycosuria and acidosis, and then making the 
attempt to have her grow and develop. The diets in the latter half of the first 



CASE RECORDS 285 

hospital period were plarmed to this end. The weight rose, but symptoms shnul- 
taneously returned. The diet at this discharge represented approximately 2.25 
gm. protein and 80 calories per kg. of body weight. Fasting and modifications of 
diet required by the occasional traces of glycosuria absolutely prevented gain or 
growth. It is not known whether a specific diabetic deficiency also may be con- 
cerned. The net result of this attempt to put on weight was, as stated, that the 
patient returned to the hospital 7 months later, weighing 2 kg. less than at 
discharge. 

After the undernutrition represented by the Oct. carbohydrate test, the diet 
was gradually built up, the weight rose with it, and the maximum of weight and 
the onset of urinary symptoms coincided (Dec, 1915). Subsequently undernu- 
trition diminished the weight and removed all active symptoms. It is obvious 
throughout that the total diet was the essential governing factor, and the relative 
proportions of protein, carbohydrate, and fat were of minor influence. The net 
result to date is that the patient is alive 3 years from the beginning of this treat- 
ment, and 4| years from the onset of her diabetes. There is no evidence of any 
spontaneous downward progress; neither has there been any fundamental'im- 
provement. The cumulative effect of slight strains and accidents may bring 
bad results sooner or later. Meantime, the patient is holding her own and is 
actually deriving enjoyment from Kfe and carrying on limited activities. The one 
requisite is close- control of her diet.* 

CASE NO. 27. 

Male, married, age 42 yrs. American; clerk. Admitted Jan. IS, 1915. 

Family History. — One sister died of cardiorenal disease at 23. Family his- 
tory otherwise negative. Patient has been married 18 years and has one healthy 
son, aged 15. Wife healthy; one miscarriage about 13 years ago. 

Past History. — Healthy life. Good hygienic surroundings. Measles and 
chicken-pox in childhood; mild diphtheria at 8; mumps at 18, complicated by 
unilateral orchitis. At about 20 there was an attack of jaundice with clay- 
colored stools lasting 2 or 3 days. At 26 one attack like acute appendicitis, 
which passed off under ice applications in a hospital. There have been indefi- 
nite minor attacks since. At 27 patient had fever every night for 28 days, with 
one hard chill at the end; then given medicine by family physician and has had 
nothing like malaria since. Occasional sore throats; never tonsillitis. Vene- 
real disease or exposure denied. Habits regular; no excesses in alcohol, tobacco, 
or food. . 

* Word has been received of the patient's death in Feb., 1918. The child her- 
self was faithful and contented, but the parents concluded to try an independent 
experiment to "build her up." The child was kept in ignorance of the glycosuria 
which quickly followed the increased diet, and the fatal outcome was due solely 
to this foUy of the parents. 



286 CHAPTER III 

Present Illness. — 8 years ago patient began to feel rather poorly, also had 
serious trouble with his teeth. Numerous teeth had to be extracted, and he de- 
veloped an infection of the mandible, some of which sloughed away. His physi- 
cian diagnosed diabetes. The carbohydrate in his diet was diminished but 
other foods were not restricted. Since that time he has had occasional attacks of 
polydipsia, otherwise no diabetic symptoms, except more or less continuous trouble 
with his teeth. Some recent worries apparently made the condition worse, but 
he remained in fair health and able to work until Jan. 3, 1915, when his neck 
began to pain and swell. He was immediately taken in charge by an eminent 
New York surgeon who had been an old-time friend. The pain required mor- 
phine, and the fever and progressive advance of the border of infection were so 
threatening that the surgeon contemplated complete excision of the infected 
area and brought the patient to this Institute with the intention of operating the 
same or the following day. 

Physical Examination.— Height 169 cm. Weight 59.6 kg. A well developed, 
fairly well nourished man, with fever, flushed face, unduly bright eyes, and ap- 
pearance of prostration. Numerous teeth missing; much caries and pyorrhea. 
On the left side of the neck behind, there is a very large carbuncle with its 
apex about midway between the postaural line and the posterior median line, 
and with marked redness and induration extending past the posterior median 
line behind and to the internal border of the sternocleidomastoid in front. The 
whole area is intensely tender and movements of the neck are prevented. Physi- 
cal examination otherwise negative. 

Treatment. — Fever was continuous, but the highest temperature was 102.5.° 
Morphine was required to control pain, particularly at night. There was a 
heavy ferric chloride reaction, and the urine on the 1st day contained 36.4 gm. 
sugar, on the 2nd day 32.4 gm. The diet on this day Qan. 16) was 87 gm. pro- 
tein, 11 gm. carbohydrate, and 1400 calories. The general condition was criti- 
cal, and the surgeon felt impelled to operate by the approach of the infection to 
the plane of the great vessels of the neck; but in view of the acidosis and nega- 
tive carbohydrate balance it was advised that operation be postponed for at least 
a day or two until the influence of fasting could be brought to bear. Accordingly, 
fasting was begun on Jan. 17, with as much whisky as could be comfortably 
taken for the sake of keeping up strength. The quantity of alcohol thus taken 
was from 700 down to 500 calories daily. After 1 day of fasting the glycosuria 
had fallen to 9.75 gm. and the general condition was at least no worse. The 
glycosuria continued to diminish on the following days and was absent on the 
4th day of fasting. Meanwhile the general condition improved, pain dimin- 
ished, the apex of the carbuncle began to discharge pus, and the night of Jan. 21 
was the first on which morphine was not required. 2 days of complete freedom 
from glycosuria were allowed to pass before the addition, on Jan. 22, of 9 gm. 
carbohydrate in the form of tomatoes, celery, and lettuce to the daily allowance 
of whisky. On Jan. 23 this was raised to approximately 20 gm., and on Jan. 



■ CASE RECORDS 287 

24 to 30 gm. On account of traces of glycosuria it was diminished on the follow- 
ing days to 6 gm., and following that both whisky and carbohydrate were in- 
creased, so that from Feb. 7 to 27 the diet was usually just below 40 gm. carbo- 
hydrate and 100 gm. alcohol daily. The fever had gradually fallen, but the 
temperature remained between 99° and 100°F. until Jan. 31, after which it was 
normal. The core of the carbuncle was extruded on Jan. 30, but full healing of 
the large local inflammation was not complete until Mar. 1. With continuance 
of the diet mentioned, the traces of glycosuria became less frequent as the in- 
fection cleared up, so that the allowance of 40 gm. carbohydrate and 100 gm. 
alcohol was fully tolerated. 

Beginning Mar. 1 a diet was gradually built up, at first containing only some 
20 gm. protein and SOO non-alcohol calories, but rising by Apr. 8 to 115 gm. pro- 
tein, 40 gm. carbohydrate, and 2650 calories. Whisky was then discontinued 
and, except for the fast-day of Apr. 11, was not used again even on fast-days. A 
regular diet was planned consisting of 90 to 100 gm. protein, 25 gm. carbohy- 
drate, and 2000 to 2200 calories; this was in the neighborhood of 2 gm. protein 
and 40 calories per kg. of body weight, reduced one-seventh by the weekly fast- 
day, so that the actual average was nearly 1.5 gm. protein and 35 calories per kg. 

After the initial critical infection was overcome, the patient had been left weak 
and debilitated, complaining of pains in the legs and other parts of the body. 
The blood pressure on Feb. 11 was down to 90 systolic, 70 diastolic. He gained 
strength while losing weight, and still more as his weight was slightly built up. 
He was encouraged to begin exercise as soon as strength permitted, and this 
was increased until at the time of discharge he was taking long walks daily. He 
had not only regained the condition present before the carbuncle, but had reached 
a state of health better than at any time during the previous years of diabetes. 
He was discharged to undertake his regular work. 

Acidosis. — ^This was measured at the outset only by the ammonia excretion, 
which was modified by alkali dosage. As a measure of precaution against the 
acidosis to be feared with an infection, sodium bicarbonate was given beginning 
Jan. 16. On this day the total taken was 15 gm., on the next day 40 gm., and 
this daily quantity was continued with scarcely any change until Feb. 3, when it 
was diminished to 10 gm. On Feb. 7 it was increased to 20 gm., on Feb. 10 to 
30 gm., and on Feb. 19 to 40 gm. This was continued until Feb. 23, when it 
was abruptly stopped. On Mar. 3, 10 gm. soda were begun and continued to 
Mar. 13, after which soda was permanently discontinued. 

The chart gives the impression that the patient had been threatened with a 
serious acidosis. The low ammonia value shown on the day of admission repre- 
sents only part of a day. The excretion of approximately 1.4 to 1.6 gm. ammonia 
nitrogen Jan. 17 to 21 occurred in spite of the considerable alkali dosage men- 
tioned. The carbon dioxide capacity of the plasma was kept within normal 
limits during this alkali treatment, at least after Jan. 29. High normal values 
were present on Feb. 18 to 22 with 30 to 40 gm. bicarbonate daily, and the am- 



288 CHAPTER III . 

monia nitrogen was also down to the low figure of 0.25 to 0.35 gm. Promptly 
with the omission of soda on Feb. 23 the plasma bicarbonate fell sharply and the 
ammonia began a corresponding steep rise. On Mar. 2 the CO2 capacity touched 
its lowest point of 43 .6 vol. per cent, and the ammonia N on the same day had risen 
to 2.8 gm. The use of 10 gm. sodium bicarbonate daily, beginning Mar. 3, pro- 
duced a rather prompt rise of the plasma bicarbonate. The ammonia fell only 
shghtly, then rose to an actually higher level on Mar. 8. The increase of pro- 
tein in the diet was presumably one factor. By Mar. 13, however, the ammonia 
nitrogen was down to 1 .68 gm. By this time the strength of the acidosis seems to 
have been broken. On Mar. 24, without alkali, the ammonia was slightly lower 
(1.4 gm. N). The next day it fell sharply to 0.56 gm., and almost simultaneously 
the ferric chloride reactions became light for the first time. The ammonia was 
equally low on the fast-day of Apr. 4. With the high diets of Apr. 5, 6, and 7 
it was higher, and fell again on the fast-day of Apr. 11. After that it varied 
between 0.4 and 1.25 gm. N. Likewise, following the discontinuance of alkali 
on Mar. 13, the plasma CO2 capacity remained little changed until Mar. 19^ 
The tests on Mar. 24 and 30 showed it falling rapidly, but it stopped at 44.2 per 
cent, and then rose spontaneously within normal limits without the aid of alkali. 

The impression is given that alkali was a useful temporary aid in this case. 
The milder grades of acidosis may be ignored, and the severer ones also can fre- 
quently be treated successfully without alkaU, but when there is a tendency to 
serious acidosis overtaxing the defenses of the alkaUne reserve of the body, both 
comfort and safety are apparently served by the use of sufficient quantities of 
alkali, which are discontinued when proper treatment has overcome the essential 
condition imderlying the acidosis. 

The ferric chloride reaction was heavy at admission and became intense fol- 
lowing the use of soda. It proved very persistent, in conformity with the other 
manifestations of the tendency to acidosis. The condition being satisfactory in 
other respects, this reaction was left to wear itself out with time and improve- 
ment of tolerance. As stated, it became negative some months after discharge, 
and has not reappeared. 

Blood Sugar. — Analyses were made during the latter part of the hospital period, 
and the relatively low values found constituted one feature of the favorable 
picture. 

Weight and Nutrition. — ^The steep fall in weight, which was intentionally re- 
duced from 59.6 kg. on Jan. 16 to 47 kg. on Mar. 4 — a loss of 12.6 kg. in 48 days — 
is one of the noticeable features of the treatment. It was necessary first to con- 
•trol radically the diabetes which was responsible for the susceptibility to infec- 
tion. Second, it was necessary to build up tolerance for carbohydrate and other 
foods, in order to save the patient from the persistent acidosis and weakness. 
These objects were accomplished by rigorous undernutrition. The patient with 
acute infection and fever was subjected to 5 days of fasting with alcohol. After 
that, nothing but a little green vegetables was added up to Mar. 1, the idea being 



CASE RECORDS 289 

to continue undernutrition while combating acidosis by the use of carbohydrate 
to the limit of tolerance under the conditions of highest tolerance; viz., exclusion 
of other food. Except for these green vegetables, there was complete depriva- 
tion of solid food for the 42 days from Jan. 17 to Mar. 1. The fall in weight 
was therefore to be expected, and from the urea and ammonia curves it is also 
possible to estimate a considerable loss of body nitrogen. It is to be empha- 
sized that under these conditions the resistance to infection apparently, and the 
general strength certainly, irnproved. Weakness and lowered resistance are to 
be regarded as due more to the specific diabetic disorder than to depletion of 
food materials, and the policy of trying to strengthen diabetic patients by feeding 
in excess of the tolerance is an injurious one. 

After the crisis was past, the condition gradually began to assume its proper 
proportions as a comparatively mild case of diabetes. In view of the patient's 
age and the demonstrated food tolerance, a fairly liberal diet was built up, 
sufficient for health and efficient work, and a moderate gain of weight was also 
permitted. At discharge, however, the weight was only 50.4 kg.; i.e., 9.2 kg. 
below the weight at entrance. The patient has since obeyed the injunction not 
to put on much flesh, and is now thin, wiry, and strong. 

Subsequent History. — The patient adhered to his diet and remained free from 
glycosuria except for a trace on June 18, after ISO gm. strawberries for break- 
fast. A moderate ferric chloride reaction was still present on Dec. 27, 1915, 
but cleared up not long after that. He later undertook work which made diffi- 
cult the accurate weighing of food, and he was therefore allowed to estimate the 
quantities from his previous experience. He has since remained free from glyco- 
suria, ketonuria, and all symptoms. He feels as well as at any time in his life 
and has risen to the position of cashier. 

The carbuncle made the diabetes worse, but the mouth condition was seemirigly 
the result rather than the cause of the diabetes; for after the therapeutic con- 
trol of the diabetes, the patient now with ordinary dental care remains free from 
tooth trouble. 

Remarks. — ^This was one of the difficult cases of serious infection which may 
cause even mild diabetes to turn suddenly severe, incidentally illustrating the 
functional as opposed to the organic element in human diabetes. Numerous 
fatalities are inevitable with such a combination. The favorable outcome in this 
case must undoubtedly be attributed largely to the fact that the carbuncle was 
near the point of discharging spontaneously, so that a few days of fasting are 
not to be credited with radical cure of the infection. On the other hand, good 
evidence is afforded that the resistance was not lowered by fasting, and the be- 
lief is that it was raised. Likewise the subsequent treatment by undernutrition 
has not made the patient susceptible to infections and other mishaps, but has 
on the contrary relieved him of these and all other diabetic complications. 



290 CHAPTER III 



CASE NO. 28. 



Female, age 11 yrs. American; schoolgirl. Admitted Jan. 19, 1915. 

Family History.— A paternal granduncle died of tuberculosis some years ago. 
No other disease in family. Father, mother, and one brother of patient entirely 
weU. 

Past History.— Healthy life. Whooping-cough at 5, measles at 6, and mumps 
at 10. A strong, active child, Uving imder good hygienic conditions in a small 
town in New York. In Aug., 1913, she had fever for 24 hours. Temperature 
was as high as 104°, and the physician could make no diagnosis. There were a 
few cases of poliomyelitis in the neighborhood about that time. For a short 
time afterward, the patient was subject to nervous movements and had pain 
in ankles without objective signs of inflammation. Habits always regular. Dis- 
position not nervous. She has been on the honor roll at school, but has been 
kept from overstudy. 

Present Illness. — While visiting in New York City after New Years day this 
year, polyuria was noticed, and when this continued several days the patient's 
mother suspected diabetes, and the diagnosis was made by her physician. The 
nervous movements noted after the previous illness were now increased. A diet 
was prescribed excluding most ordinary carbohydrates, but including gluten bread, 
toast, and milk. 

Physical Examination. — A healthy looking girl, well nourished and rather 
large for her age. The face appears nervous, and there are twitching or chorei- 
form movements of the head and arms. Teeth in good condition. Tonsils 
hypertrophied. Enlargement of epitrochlears but not of other lymph nodes. 
Knee and other reflexes exaggerated. Examination otherwise negative. 

Treatment.^-The glycosuria of 1.6S per cent present when patient was brought 
to the hospital ceased immediately on a carbohydrate-free diet of 600 to 650 
calories, but the ferric chloride reaction, which had been negative, developed in 
moderate intensity on the second day of this diet. 2 fast-days were then im- 
posed Qan. 21 and 22), and the ferric chloride color became intense. Green 
vegetables were begun in the usual manner on Jan. 23 and increased until the 
limit of tolerance seemed to be reached with 133 gm. carbohydrate on Feb. 1. 
Instead of a fast-day on Feb. 2, the vegetables were merely diminished to 36 
gm. carbohydrate. Under this program the ferric chloride reaction had become 
much paler, the ammonia nitrogen had fallen from 0.85 gm. on Jan. 25 to very 
low figures, and the plasma bicarbonate had risen from 47 per cent on Jan. 25 
up to the lower normal Umit. Carbohydrate-free diet was begun on Feb. 3 with 
two eggs, 20 gm. butter, and 250 gm. thrice cooked vegetables. This diet was 
rapidly increased and carbohydrate introduced. On Mar. 1 to 3 the patient 
proved able to tolerate 80 to 90 gm. protein, 50 gm. carbohydrate, and 3000 
calories, without glycosuria but with persistence of a sUght ferric chloride reac- 
tion. She was discharged Mar. 5 on a diet of 72 gm. protein, 30 gm. carbohy- 
drate, and 2500 calories (approximately 2.5 gm. protein and 90 calories per kg.). 



292 CHAPTER m 

lation was actually diminished. Carbohydrate up to 140 gm. was tolerated per- 
fectly, then heavy glycosuria occurred. The child was brought to confess that 
this was due to stealing bread, and that the difficulties in the preceding months 
had been due to the same cause. By Oct. 12 she was taking 75 gm. protem, 
30 gm. carbohydrate, and 1500 calories, weighed 86 pounds, and had grown 2i 
inches since leaving hospital. On Jan. 10, 1917, the first menstrual period ap- 
peared in normal manner, but none has appeared since that time. The re- 
port on Jan. 18, 1917, showed that she was taking 80 gm. protein, 24 gm. carbo- 
hydrate, and 1625 calories, and weighed 901 pounds. 

In Mar., 1917, she went through German measles without glycosuria. There 
have been occasional traces of glycosuria, the trouble being partly due to indulgent 
management, but these traces are always cleared up immediately and com- 
pletely by fasting. The patient feels and appears entirely well and is continuing 
normal activities. 

Remarks. — The history suggests that this is a case of diabetes resulting from 
an acute infection. If so, the damage produced was not transitory. The pa- 
tient remains diabetic, and is liable to take an unfavorable turn from some acci- 
dental disturbance at almost any time; spontaneous downward progress is not 
noted. There is a definite improvement, but not to any extent suggesting a 
complete cure. If such improvement can continue the ultimate outcome may be 
very favorable. Actual recuperation to this degree, especially on rather high 
diets, is unusual, and possibly stands in relation to an exceptional etiology. If 
diabetes is caused by a transitory infection, the repair of the damage may some- 
times be partial instead of complete. Possibly childhood may actually favor re- 
pair under the special conditions. In the absence of complete recovery, there is 
no doubt that neglect of diet will entail rapid downward progress. Dietetic 
treatment may save in proportion as it is early and effective. If the improve- 
ment can continue, the ultimate outcome in this particular patient may be very 
favorable. Thus far at any rate, in this case of juvenile diabetes, taken at an 
early, fairly mUd stage, it has been possible through 2 J years to obtain improve- 
ment rather than downward progress, along with seemingly normal growth and 
development.* 

CASE NO. 29. 

Female, unmarried, age 26 yrs. Finnish; domestic. Admitted Jan. 27, 1915. 

Family History. — ^Parents are living; both have heart trouble. One brother is 
well. Two sisters died of tuberculosis and three others of unknown causes in 
adult life. Family history otherwise negative for tuberculosis, cancer, syphilis, 
and diabetes. 

Past History. — Healthy life, spent in comfortable circumstances on farm in 
Finland up to 3 years ago, since then patient has been employed as domestic 

* A relapse has occurred, and the patient has been referred elsewhere for treat- 
ment. The experience is a further warning of the pernicious effect of high diets. 



CASE RECORDS 293 

in the better parts of New York. For the past i months she has been a cook. 
No illness remembered, except whooping-cough in childhood. Occasionally- 
patient spits a little bright red blood. Diet has been rich in starch but not in 
sweets. No excesses or bad .habits. 

Present Illness. — ^Just after the recent Christmas holidays the patient first 
noticed weakness, weariness, polyphagia, polydipsia, and the loss of IS pounds 
weight. A physician immediately diagnosed diabetes. 

Physical Examination. — A well appearing, fairly well nourished young woman. 
Teeth in good condition. Throat sUghtly congested; tonsils show neither hy- 
pertrophy nor exudate. Cervical, epitrochlear, and inguinal lymph nodes not 
palpable. Axillary glands are shot-like. General examination negative. Blood 
pressure 110-90. 

Treatment. — ^The partial urine specimen on the day of admission showed 1.69 
per cent, or 7.52 gm. sugar. On the next day (Jan. 28), on a carbohydrate-free 
observation diet of 68 gm. protein and 1350 calories there was glycosuria of only 
2.1 gm. Anorexia had come on before admission, so this diet was aU the patient 
cared to take. On Jan. 29 fasting was begiin^ and on the subsequent days as 
much as 100 cc. whisky were allowed; larger quantities could not be taken be- 
cause of nausea. The urine immediately became sugar-free, but a weU marked 
ferric chloride reaction persisted, partly perhaps because of the use of sodium 
bicarbonate. Because of the slightly subnormal CO2 capacity of the plasma 
and the seeming tendency to weakness and nausea, 50 gm. sodium bicarbonate 
had been given on the first day of fasting (Jan. 29) and 100 gm. on the second 
fast-day (Jan. 30). The cUnical condition was not perceptibly altered, and 
gave no indication of either benefit or injury. On Jan. 31, after the urine had 
been sugar-free over 72 hours, green vegetables were allowed containing 5 gm. 
carbohydrate. This quantity was increased up to 100 gm. carbohydrate on 
Feb. 4 and 5. This was tolerated without glycosuria. But with the protein-fat 
diet of 1200 to 1700 calories (Feb. 8 to 12), traces of glycosuria occurred 
with an intake of only 9 gm. carbohydrate. 

Owing to the persistence of ferric chloride reactions, another period of alcohol 
and green vegetables was given up to Feb. 25. Thereafter only traces of glyco- 
suria resulted from very high diets; e.g., 90 gm. protein, 35 gm. carbohydrate, 
and 3600 calories on Mar. 8 to 10. The diet was then adjusted so that at dis- 
charge on Apr. 21 it consisted of 90 gm. protein, 50 gm. carbohydrate, and nearly 
3000 calories (approximately 2 gm. protein and 70 calories per kg.). The weight, 
which had been markedly reduced during undernutrition up to Feb. 25, increased 
on the higher diets, so that at discharge it was almost at the admission level. 

All symptoms had disappeared and the patient felt entirely well. Radio- 
graphs and repeated sputum examinations failed to reveal any tuberculosis. 

In Apr. the patient received word that her only brother had died of tubercu- 
losis. She therefore insisted upon returning to Finland. The bad news and the 
preparations for departure brought on no glycosuria. She was given a letter to 
a professor in Helsingfors, and was warned to remain free from glycosuria under 
all conditions. 



294 CHAPTER ni 

Remarks. — ^The case is not instructive. Even with allowance for the weekly 
fast-days the diet was too high for permanently good results. The patient was 
ignorant of the gravity of her condition and it was judged that she would not ad- 
here to any serious restrictions, and this became more certain when she decided 
to return to Finland. Rather than have her break away from restrictions alto- 
gether, it seemed advisable to plan a diet adequate to permit her to work and 
feel well for the present and not attempt a more ideal result. Nothing has been 
heard of the patient since discharge. 

CASE NO. 30. 

Female, married, age 45 yrs. American; housewife. Admitted Jan. 30, 
1915. 

Family History.— FsLthei is living, aged 72. Mother died at 47, following 
operation for fibroids. One sister died at 35, following operation for an old 
traumatic hip; three sisters are well. No diabetes or other special diseases 
known in family. Patient has been married 25 years and has had seven chil- 
dren; three are alive and well, the others died in infancy when the mother was in 
bad condition or suffering from grippe or typhoid. 

Past History. — Usual childhood diseases (history indefinite). Typhoid fever 
25 years ago. Grippe at several times; no sore throat. Appendicitis 8 years ago; 
operation. 7 years ago curettage for menorrhagia. Operation for mastoiditis 6 
years ago. For some years past the patient has been nervous and suffered from 
nervous indigestion. Feces have also been pale, but never showed blood. Habits 
have been regular, diet simple; no excesses. 

Present Illness. — First symptom was pruritus vulvae 7 months before admission, 
followed by marked polyphagia, polydipsia, and poljTiria. She sought no treat- 
ment for 4 months, then was placed on a diet, carbohydrate-free except for green 
vegetables and one sUce of toast. She has lost 35 pounds weight. During 2 
days prior to admission to hospital her physician had placed her on absolute 
fasting with whisky and sodium bicarbonate. 

Physical Examination. — ^Woman without dyspnea or acute symptoms, moder- 
ately weak. Body shows evidence of considerable loss of weight, but still carries 
fair quantity of fat. Eyes react normally and ophthalmoscopic examination is 
negative. Teeth are in good repair. Throat congested; tonsils free from exu- 
date or hypertrophy. Cervical and inguinal glands not palpable, axillaries and 
epitrochlears slightly enlarged. Knee jerks obtained only on reinforcement, and 
then sluggishly. Achilles jerks present. Blood pressure 110 systolic, 85 diastolic. 
General examination negative. 

Treatment. — Patient seemed in fair condition and in no danger when admitted. 
Only shght glycosuria was present, and only a moderate ferric chloride reaction. 
She was admitted in the afternoon and received supper consisting of soup, 100 gm. 
steak, and 100 gm. raw and 100 gm. thrice cooked vegetables. She was men- 
struating, and had slight diarrhea. A phenolphthalein tablet and 15 gm. mag- 



CASE RECORDS 295 

nesium sulfate produced small liquid or soft movements which continued undSr 
small doses of cascara on the following days. On the first full day in hospital 
(Jan. 31) the diet consisted of 81 gm. protein, 5 gm. carbohydrate, and 1650 cal- 
ories. Glycosuria was entirely absent, the ferric chloride reaction still only 
moderate, and the condition apparently satisfactory. The next day, Feb. 1, 
the diet consisted of SO gm. protein, 12 gm. carbohydrate, and 1250 calories. The 
patient showed slight nausea. On Feb. 2, the diet consisted of coffee, soup, one 
egg, and 600 cc. milk, representing 27 gm. protein, 30 gm. carbohydrate, and 500 
calories. Nausea had increased, and on this day the patient vomited once a 
little undigested food. She said she had often had such attacks with her indi- 
gestion in the past. With small doses of chloretoUe, also a Seidlitz powder fol- 
lowed by a saline enema which removed considerable feces, the nausea seemed 
greatly diminished. Meanwhile a trace of glycosuria had appeared from the 
carbohydrate, and the ferric chloride reaction had become intense, but the highest 
ammonia nitrogen output (Feb. 2) was 1.9 gm. On Feb. 3, the diet was limited 
to 300 cc. clear soup, 300 cc. milk, and 90 cc. whisky. The patient also received 
3 cc. aromatic cascara, 30 cc. Pluto water, and 10 gm. sodium bicarbonate. On 
Feb. 4, as glycosuria and ketonuria were well marked and the patient was slightly 
nauseated, a fast-day was given, the entire intake being 150 cc. coffee, 130 cc. 
whisky, 15 gm. sodium bicarbonate, 3 cc. aromatic cascara, and 30 cc. Pluto 
water. Though the urine remained acid, the glycosuria diminished to a trace, 
ammonia fell to 0.87 gm. N, and the CO2 capacity of the plasma, which had been 
only 35.8 per cent on Feb. 2, rose to 57.7 vol. per cent on Feb. 4. Feb. 5 was also a 
fast-day, the intake being 140 cc. whisky and 15 gm. sodium bicarbonate. The 
urine remained acid. In the morning the patient felt well; toward evening she 
was slightly dizzy and nauseated. Feb. 6 was also a fast-day with 125 cc. whisky 
and 25 gm. sodium bicarbonate. The symptoms were more alarming; the tem- 
perature was 99.2°F., the pulse 90, the respiration 20; the pulse was weak, and the 
patient complained of dizziness and vomited several times. Two doses of 0.5 
gm. chloretone were given for the vomiting, and 2 gm. compound jalap powder 
to empty the bowels further, though there had been one or more defecations 
every day. 

On Feb. 7 only 25 cc. whisky could be taken because of nausea. Vomiting 
continued notwithstanding the use of a variety of routine measures, and weakness 
was becoming serious. The temperature first was as high as 99.8°, but fell by 
the close of the day to 96°. The pulse ranged 100 to 130, the respiration 28 to 
44. Caffeine was administered at intervals subcutaneously, and later camphorated 
oil. An attempt also was made to feed, and milk, eggs, and beef juice were 
given and partly vomited. 1 liter of 4 per cent sodium bicarbonate solution was 
successfully given by the rectal drip method. The patient had become very 
drowsy, almost unconscious. 

On Feb. 8, eggs and beef juice were continued, as also the caffeine and cam- 
phorated oil. Levulose was also given in small doses totahng 140 gm.; it was 



CASE RECORDS 295 

nesium sulfate produced small liquid or soft movements which continued under 
small doses of cascara on the following days. On the first full day in hospital 
(Jan. 31) the diet consisted of 81 gm. protein, 5 gm. carbohydrate, and 1650 cal- 
ories. Glycosuria was entirely absent, the ferric chloride reaction still only 
moderate, and the condition apparently satisfactory. The next day, Feb. 1, 
the diet consisted of SO gm. protein, 12 gm. carbohydrate, and 1250 calories. The 
patient showed slight nausea. On Feb. 2, the diet consisted of coffee, soup, one 
egg, and 600 cc. milk, representing 27 gm. protein, 30 gm. carbohydrate, and 500 
calories. Nausea had increased, and on this day the patient vomited once a 
little undigested food. She said she had often had such attacks with her indi- 
gestion in the past. With small doses of chloretotxe, also a Seidlitz powder fol- 
lowed by a saline enema which removed considerable feces, the nausea seemed 
greatly diminished. Meanwhile a trace of glycosuria had appeared from the 
carbohydrate, and the ferric chloride reaction had become intense, but the highest 
ammonia nitrogen output (Feb. 2) was 1.9 gm. On Feb. 3, the diet was limited 
to 300 cc. clear soup, 300 cc. milk, and 90 cc. whisky. The patient also received 
3 cc. aromatic cascara, 30 cc. Pluto water, and 10 gm. sodium bicarbonate. On 
Feb. 4, as glycosuria and ketonuria were well marked and the patient was slightly 
nauseated, a fast-day was given, the entire intake being 150 cc. coffee, 130 cc. 
whisky, 15 gm. sodium bicarbonate, 3 cc. aromatic cascara, and 30 cc. Pluto 
water. Though the urine remained acid, the glycosuria diminished to a trace, 
ammonia fell to 0.87 gm. N, and the CO2 capacity of the plasma, which had been 
only 35.8 per cent on Feb. 2, rose to 57.7 vol. per cent on Feb. 4. Feb. S was also a 
fast-day, the intake being 140 cc. whisky and 15 gm. sodium bicarbonate. The 
urine remained acid. In the morning the patient felt well; toward evening she 
was slightly dizzy and nauseated. Feb. 6 was also a fast-day with 125 cc. whisky 
and 25 gm. sodium bicarbonate. The symptoms were more alarming; the tem- 
perature was 99.2°F., the pulse 90, the respiration 20; the pulse was weak, and the 
patient complained of dizziness and vomited several times. Two doses of 0.5 
gm. chloretone were given for the vomiting, and 2 gm. compound jalap powder 
to empty the bowels further, though there had been one or more defecations 
every day. 

On Feb. 7 only 25 cc. whisky could be taken because of nausea. Vomiting 
continued notwithstanding the use of a variety of routine measures, and weakness 
was becoming serious. The temperature first was as high as 99.8°, but fell by 
the close of the day to 96°. The pulse ranged 100 to 130, the respiration 28 to 
44. Caffeine was administered at intervals subcutaneously, and later camphorated 
oil. An attempt also was made to feed, and milk, eggs, and beef juice were 
given and partly vomited. 1 liter of 4 per cent sodium bicarbonate solution was 
successfully given by the rectal drip method. The patient had become very 
drowsy, almost unconscious. 

On Feb. 8, eggs and beef juice were continued, as also the caffeine and cam- 
phorated oU. Levulose was also given in small doses totaling 140 gm.; it was 



296 CHAPTER m 

retained but had no evident effect. At 4 p.m., 700 cc. 4 per cent sodium bicar- 
bonate were given intravenously. At 10 p.m. 100 cc. were likewise given. The 
temperature had slowly risen, and continued to rise, reaching 101° F. at 7 p.m. 
on Feb. 8, 101.8° at 1 a.m. on Feb. 9, and 104° at 5 a.m. The pulse remained 
about 140, the respiration 40 to 48. Toward the close the picture was that of 
fully developed diabetic coma. Death occurred at 6:45 a.m. on Feb. 9. 

Remarks. — ^This was the first case seen at this Institute showing development 
of fatal acidosis on fasting, and the treatment was mistaken because the condi- 
tion was unexpected. The very rapid loss of weight, from 56.8 kg. on Jan. 31, 
down to 52.2 kg. on Feb. 7, is a significant feature apparently present in all such 
cases. One error in treatment is the low fluid intake and correspondingly low 
output as shown in the graphic chart. Salts should also have been more liberally 
suppUed. But the chief lesson for such cases is to break off fasting when the 
first warning symptoms appear, and after a period of some days of feeding to 
repeat the fast, which then is well borne. Suitable preparatory feeding preceding 
the initial fast will doubtless also prevent all or nearly all such mishaps. 

CASE NO. 31. 

Male, unmarried, age 35 yrs. American; real estate agent. Admitted Feb. 
12, 1915. 

Family History. — Mother is well except for occasional rheumatism. Father 
died of sarcoma at 62. One brother and two sisters are well; two died in in- 
fancy. No knowledge of any family disease. 

Fast History. — Patient has lived all his life in New York City in good health 
and hygienic surroundings. Measles and whooping-cough in childhood. Gonor- 
rhea 10 years ago. SyphiUs denied; two Wassermann tests in the past have 
been negative. In 1889, after ^exposure to a great blizzard in winter, the patient 
suffered from inflammatory rheumatism in the spring. This returned almost 
yearly until 1895, when he received treatment by medicine, which ended the 
rheumatism permanently but left him with persistent bad digestion. 12 years 
ago he had St. Vitus' dance, which was cured in a German sanitariimi b}'- rest 
and arsenic. He has sore throats every year. No excesses in food, drink, or 
tobacco. Since becoming diabetic he has lost about 35 pounds weight. For 
about a week past he has had pain in the great toe of the right foot. 

Present Illness. — 3 years ago debility without other sjrmptoms began. The 
urine was found to contain 5 per cent sugar. This gradually cleared up on 
carbohydrate-free diet with addition of one sUce of bread at each meal. In 1913 
he became worse and was placed in a hospital, where 3 green days cleared up gly- 
cosuria. Since leaving the hospital he has constantly had 3 to 5 per cent sugar 
in the urine. He continued work up to 4 months ago; since then he has been 
physically and mentally incapacitated. 

Physical Examination. — Sallow color; only moderate emaciation; acetone odor 
present. Teeth in good repair. TonsUs and throat normal. Axillary glands 



CASE RECORDS 297 

palpable, but not cervical, epitrochlear, or inguinal. Arteries are palpably scler- 
otic. Blood pressure 90 systolic, 75 diastolic. Knee jerks sluggish; Achilles jerks 
active. The great toe of the right foot shows a slight abrasion. The toe is 
bluish in color, cold to the touch, and the skin between it and the next toe is 
lifted up by exudate. Examination otherwise negative. 

Treatment.— There were 2 days of observation diet. On Feb. 13, the first full 
day in hospital, this consisted of 84 gm. protein, 6 gm. carbohydrate, and 1830 
calories. The glycosuria on this day was 31.3 gm., and the ferric chloride reac- 
tion was strong. Fasting was then begun, particularly with a view to the in- 
cipient gangrene. Whisky was permitted in quantities up to 500 calories of 
alcohol. On Feb. 17, whisky was diminished to 30 cc, and 9 gm. carbohydrate 
were added. Glycosuria, which had been absent, returned in traces and con- 
tinued for 2 days longer, though the carbohydrate on Feb. 18 was diminished to 
4 gm., and on Feb. 19 only whisky and 350 gm. thrice cooked vegetables were 
given. These traces of glycosuria were accidental, or else continued undernutri- 
tion brought rapid improvement; for beginning Feb. 20, 40 to 50 gm. carbo- 
hydrate in the form of green vegetables were given daily without glycosuria, 
vmtil Feb. 25. On Feb. 26, the carbohydrate was diminished to 10 gm. The 
whisky was now 170 cc. Glycosuria ceased, but reappeared Mar. 3 on a diet 
of 70 gm. protein and 1700 calories without carbohydrate. It became heavier 
as the calories were increased to 2300, stopped with the fast-day of Mar. 7, re- 
appeared with the carbohydrate-free diet of 2300 calories on Mar. 8, and ceased 
when the diet was cut down to 1200 calories Mar. 9 to 11. There were no 
vegetables of any kind in these later diets, so the glycosuria was evidently due 
to the protein-fat intake. Thrice cooked vegetables were then added and were 
at first tolerated, but glycosuria reappeared on Mar. 13, 14, and 15, on diets lower 
in protein and calories than those formerly assimilated. Though the vegetables 
on these days consisted only of 150 gm. string beans and 100 gm. celery, both 
thrice boiled, the glycosuria was evidently due to this trifle of carbohydrate. 
This very low tolerance improved with continued undernutrition and the dim- 
inution of other elements in the diet. Thus, beginning Mar. 17, the same 
thrice boiled vegetables were tolerated, the protein now being 30 gm. and the 
total calories 400. This diet was gradually built up and on Apr. 3 a trace of 
glycosuria appeared with 75 gm. protein, 200 gm. thrice boUed vegetables (string 
beans and asparagus), and 1700 calories. This stopped on the fast-day of Apr. 
4; and on Apr. 5, 5 gm. carbohydrate in the form of asparagus, celery, and lettuce, 
without other food, were tolerated without glycosuria. Beginning Apr. 6 the 
protein was diminished to 40 gm. and the calories to 1400. With this reduction 
in protein, not only did the same quantity of thrice cooked vegetables cause no 
glycosuria, but also on Apr. 9 and 10 the addition of 10 gm. carbohydrate was tol- 
erated. The attempt during the ensuing week (Apr. 12 to 17) to raise the carbo- 
hydrate to 20 to 30 gm. and the calories to 1800 resulted in slight glycosuria. 
The tendency to glycosuria gradually diminished, and by July 7 the patient had 



298 CHAPTER m 

become able to tolerate 80 gm. protein, 25 gm. carbohydrate, and 2150 calories 
(over 1.5 gm. protein and 40 calories per kg. for a weight of SO kg., but dimin- 
ished one-seventh by the weekly fast-days). He was dismissed on this diet in 
good condition. 

Acidosis. — This was never acutely threatening. The ferric chloride reaction 
was fairly persistent. It cleared up with the undernutrition at the close of Mar., 
and returned with the higher diets in Apr., even though carbohydrate was soon 
added to these diets. Then, without special change in the diet, the ferric chloride 
reaction gradually disappeared and was absent at discharge. 20 gm. sodium bi- 
carbonate were given daily Feb. IS to 22. On Feb. 23, it was diminished to 5 
gm., and then stopped. The carbon dioxide capacity of the plasma, as far as 
observed after Mar. 18, was within or near normal Umits, and was high at 
discharge. 

Blood Sugar. — ^This fluctuated, but hyperglycemia was the rule. The last 
analysis on June 24 still showed 0.165 per cent. It is evident that hyperglycemia 
did not prevent continued improvement in tolerance and sjonptoms. Neverthe- 
less, this hjrperglycemia is an unfavorable feature. It could doubtless have been 
brought lower, but the patient was unintelligent and untrustworthy. For this 
reason an ideal result was not considered possible in his case, and a fairly satis- 
fying diet was therefore permitted, with some hope that improvement might stiU 
be possible, if he remained continuously free from glycosuria. 

Weight and Nutrition. — The rise of 5 kg. in weight from Feb. 15 to 23 was 
due to edema resulting from the sodium bicarbonate. The weight fell rapidly on 
stopping the bicarbonate. Beginning May 31 there was another onset of edema 
independent of bicarbonate or other known cause. Albumin and casts were 
absent from the urine. The entire gain in weight from May 31 to June 16 was 6 
kg. That this was wholly due to fluid retention, apparently from renal cause, 
is shown by the prompt fall following June 16, when salt-free diet was instituted. 
The entire period in hospital represented undernutrition such that the weight was 
diminished by 4 kg. There was clinical benefit instead of injury. Under the 
fasting and subsequent treatment the threatened gangrene cleared up smoothly. 
Strength was regained, the appearance and color improved, and at discharge the 
patient was able to resume his work, in contrast to the state of incapacity at the 
time of admission with higher weight and active diabetes present. 

Subsequent History. — ^The patient followed diet and showed normal urine for 
several months. In Aug. he passed through a severe bronchitis without show- 
ing sugar. Toward Oct. he had much business worry, and analysis showed 0.204 
per cent sugar in the whole blood and 0.278 per cent in the plasma (probably 
more dietetic than psychic in origin, however). The patient rejected the advice 
to return to the hospital at this time because of business emergencies which he 
must meet. He again reported at the hospital on Nov. 29. Meantime he had 
been traveling through other states under conditions which prevented following 
diet. The blood sugar was 0.227 per cent, plasma sugar 0.244 per cent. He was 



CASE EECOBDS 299 

instructed as to becoming sugar-free at home, and on Dec. 5 reported that glyco- 
suria had stopped with 1 day of fasting and had remained absent on his regular 
diet. The urine on this date was normal, the blood sugar 0.208 per cent,^ the 
plasma sugar 0.2S0 per cent. On Dec. 12 a trace of glycosuria appeared, and 
the patient therefore fasted on Dec. 13. The urine was normal, the blood sugar 
0.178 per cent, the plasma sugar 0.213 per cent. The patient was continually 
inclined to carelessness, but felt worse when showing sugar and therefore made 
some attempts at following diet. On Dec. 28 he returned to the hospital. 

Second Admission. — ^The urine showed slight sugar and ferric chloride reac- 
tions. On the observation diet of Dec. 29, comprising 77 gm. protein, 15 gm. 
carbohydrate, and 2000 calories, a trace of glycosuria persisted in the early hours 
but cleared up before the close of the day. A fast-day was nevertheless imposed 
on Dec. 30, followed by a routine carbohydrate test, which fixed the tolerance at 
70 gm. carbohydrate. On the subsequent diets entirely unaccountable traces of 
glycosuria occurred, and the patient finally proved to be repeatedly violating 
diet. On account of his persistent carelessness and disobedience, he was dis- 
missed and was referred to a local speciahst, with the idea that he might appre- 
ciate treatment more if he had to pay for it. 

Remarks. — On the fast-day of Dec. 30 the blood sugar was 0.111 per cent and 
the plasma sugar 0.122 per cent. It is seen that the body weight at the second 
admission was identical with that at the former discharge. Notwithstanding 
repeated indiscretions in carbohydrate, the patient had kept down his total diet 
approximately as directed, and the tendency to a lowering of the hyperglycemia, 
as hoped for at the previous discharge, had actually shown itself. The case had 
been characterized by very low tolerance in the initial period of the first admission, 
but, in consequence of the undernutrition then imposed, had become easy to man- 
age. The only difficulty was the light-mindedness of the patient. He was dis- 
charged in favorable clinical condition, with prognosis governed by behavior. 

CASE NO. 32. 

Female, married, age 21 yrs. Russian Jew; housewife. Admitted Feb. 18, 
1915. 

Family History. — Father died when patient was an infant. Mother well at 
51. One brother and one sister well. No heritable disease known. 

Past History. — Considerable sickness in infancy. Diphtheria complicated by 
measles at 2i years. Pneumonia at 3 years. Healthy life since then. Habits 
regular. Diet largely carbohydrate, but no sugar. Married 3 years, has a 
healthy 2 year old child. The only recent illness was a 2 day attack of tonsil- 
litis 2 years ago. 

Present Illness.— Last June began polyphagia, polydipsia, polyuria, weakness, 
headache, and pains in legs. Recently pruritus vulvae. Menstruation stopped 
last Oct. Patient supposed all the symptoms due to pregnancy, and was sur- 
prised when a physician found pregnancy absent and diagnosed diabetes. She 
was sent to this hospital for impending coma. 



300 CHAPTER ni 

Physical Examination. — Height 168.5 cm. A well developed and nourished 
young woman, with flushed face and drowsy expression. Dyspnea is present; 
respiration about 30 per minute. Teeth in fair condition; some pyorrhea. Ton- 
sils moderately hypertropMed; the left axillary and epitrochlear glands pal- 
pable; cervical and inguinal not palpable. Knee jerks not obtainable; Achilles 
jerks present. Blood pressure 100 systolic, 65 diastolic. Faint albuminuria. 

Treatment. — Because of the imminent danger of coma, fasting was begun im- 
mediately, with some 400 to 600 calories of whisky daily. Th^ patient was con- 
scious though sleepy, and not nauseated. On Feb. 18 she received 10 gm. 
sodium bicarbonate and 2 gm. compound jalap powder; 30 gm. sodium bicarbon- 
ate on Feb. 20 and 21,10 gm. on Feb. 22. She was thirsty, and was able to drink 
as much as 3 liters of water daily, but the main reliance was placed on fasting. 
Both the glycosuria and the clinical symptoms rapidly cleared up. The urine 
became neutral on Feb. 21. Glycosuria was absent on Feb. 23, but the first food 
was allowed on Feb. 26. This consisted only of 12 gm. carbohydrate in the form 
of green vegetables. By Mar. 6 it had been increased to 50 gm. carbohydrate 
without glycosuria. The whisky meanwhile was continued at 500 calories daily. 
It might have been well to have pushed the carbohydrate to the point of glycosuria, 
with a view to clearing up the remaining slight ferric chloride reaction. But 
after the fast-day with whisky on Mar. 7, protein-fat diet was begun. On Mar. 
10 whisky was permanently stopped. The diet was gradually built up to 118 
gm. protein, 25 to 27 gm. carbohydrate, and 2600 to 2800 calories (approximately 

2.4 gm. protein and 52 to 56 calories per kg. on 50 kg. weight, reduced one-seventh 
by the weekly fast-days), with only transient traces of glycosuria. She was 
dismissed Apr. 7 on a diet of 85 gm. protein, 20 gm. carbohydrate, and 2500 cal- 
ories (1.7 gm. protein and 50 calories per kg. reduced by weekly fast-days to 

1.5 gm. protein and 43 calories average). This was weU below what she had 
seemed able to tolerate. At discharge she was to all appearances entirely healthy. 

Acidosis. — ^The carbon dioxide capacity of the plasma was only 26.4 vol. per 
cent at admission. Fasting was evidently the most important factor in raising it, 
for on Feb. 19, after only 10 gm. sodium bicarbonate, it had risen to 38.5 per 
cent. Under the larger doses of bicarbonate it rose still more rapidly to the 
high normal figure of 64.6 per cent on Feb. 22. This was an artificial elevation 
resulting from the alkali dosage, for with discontinuance of alkali the COa ca- 
pacity fell steeply to 45 per cent on Feb. 25. Under the influence of the small 
quantities of carbohydrate it rose spontaneously within normal limits, reaching 
62.2 per cent on Mar. 4, without the aid of alkali. It fell on the fast-day of Mar. 
7, alcohol alone being apparently unable to hold it up. It continued to fall, on 
addition of protein and fat, down to 46.5 per cent on Mar. 10. The steep rise to 
56 per cent on Mar. ll and 60 per cent on Mar. 12 is perhaps explainable by the 
introduction of 75 gm. protein in the diet. From this time the curve tends to 
run near or slightly below the lower normal limit, and was barely at this limit 
at discharge. The ferric chloride reaction was intense at the outset, diminished 



CASE RECORDS 301 

rapidly during the fast, and was down to traces during the ensuing carbohydrate 
period. The later diet being a high one, this reaction did not become perma- 
nently negative in hospital. Notwithstanding the use of alkali, the ammonia 
nitrogen on Feb. 19 was up to 3.54 gm. It fell as steeply as the plasma bicar- 
bonate rose. Its general course was still downward after discontinuance of 
alkali, but with the beginning of protein-fat diet, as the CO2 capacity fell, the 
ammonia again rose, up to 1.9 gm. N on Mar. 11, with a fall thereafter, perhaps 
partly because of introduction of carbohydrate, perhaps partly because of the 
improved condition. No clinical symptoms were associated with the persistent 
traces of ferric chloride reaction and chronically low CO2, and the use of alkali 
was not indicated. 

Blood, Sugar. — ^This was down to 0.128 per cent on the morning of Mar. 22, 
following the preceding fast-day. On Apr. 3, at the close of a week of high diet, 
it was up to 0.192 per cent. Following the fast-day of Apr. 4, the blood sugar 
on the morning of Apr. 5 was found to have returned promptly to the normal 
level of 0.117 per cent. At discharge on Apr. 7 it was 0.133 per cent. It could 
have been kept rigidly within normal limits, but a gradual fall was hoped for 
with continued improvement under suitable diet. 

Weight and Nutrition. — ^The initial fall in weight during fasting was moderate, 
amounting to 2 kg. in 8 days. The bicarbonate did not produce edema, but 
beginning Feb. 26 the green vegetables produced a definite water retention, as 
often happens, so that the weight on Mar. 2, after practically continuous fasting, 
was 1 kg. higher than at admission. This slight but visible edema cleared up 
spontaneously and did not return. It wUl be noted that the initial fasting 
treatment, which cleared up the impending coma, consisted in 18 days of total 
abstinence from food, except the moderate quantities of alcohol and trifle of 
green vegetables. The weight fell from 53.2 kg. on Feb. 18 to 49 kg. on Mar. 
9, a loss of 4.2 kg. Later with higher diets it tended to rise slightly, but was 
only 50 kg. at discharge; i.e., 2.3 kg. less than at admission. It was hoped that 
the case was mild enough to permit a moderate gain in weight, and as the patient 
had to work, a liberal diet was allowed as described. 

Subsequent History. — ^This patient, though poor and uneducated, adhered 
strictly to dietary instructions. The urine was continuously free from sugar 
and the ferric chloride reaction had disappeared, therefore lO gm. carbohydrate 
were added to the diet on May 26. On June 4, the blood sugar was 0.105 per 
cent; on June 11, 0.122 per cent in the whole blood, 0.143 per cent in the plasma. 
The weight had risen to 56.3 kg. By Oct. 12, it had risen to 62.3 kg. The blood 
sugar then was 0.130 per cent and the CO2 capacity of the plasma 66.2 vol. per 
cent. The diet was then increased by 200 cc. milk, as the patient reported her- 
self not yet quite up to full workiiig strength. On Nov. 3, the sugar in the 
blood was 0.149 per cent, in the plasma 0.175 per cent, and the CO2 capacity was 
56.3 per cent. 

On Nov. 22, the sugar in the blood was 0.130 per cent, in the plasma 0.143 



302 CHAPTER III 

per cent, and CO2 capacity 42.5 per cent. The first trace of sugar was reported 
in the urine. 

On Dec. 6, the patient reported having had cold and cough for 10 days. The 
urine remained normal, and she probably ate less than usual, for the sugar was 
found to be 0.100 per cent in the blood, 0.105 per cent in the plasma; the CO2 
capacity 65.5 per cent. 

On Dec. 23, the patient reported at the hospital with fever of 100°, com- 
plaining of pains in joints and chest. She continued to feel badly and lost a 
few pounds in weight. The urine remained normal. Her menstruation, which 
had returned in the autumn, had again ceased. 

On Dec. 27, she was readmitted because of her cold or grippe, though diabetic 
symptoms were absent. 

Second Admission. — Coryza was present, but the general appearance was good. 
Temperature was never above 99.8°F. The body weight was now 58.3 kg., as 
compared with 53.2 kg. at the first admission. Glycosuria was present Dec. 
29 to 31, on a diet of 90 gm. protein, 50 gm. carbohydrate, and 2075 calories (1.54 
gm. protein and 35.6 calories per kg.). The low blood sugars recorded mornings 
before breakfast show the absence of any continuous hyperglycemia. The am- 
monia nitrogen was 0.73 gm., and the total acidity (Henderson) 205. A carbo- 
hydrate tolerance test was instituted in the usual manner, beginning with a fast- 
day on Jan. 2. The increase in carbohydrate was made more rapidly than usual 
because of the high tolerance, which was found to be approximately 180 gm. 
carbohydrate. The patient was discharged on Jan. 16, 1916, weighing 57.8 kg., 
with a prescribed diet of 100 gm. protein, 50 gm. carbohydrate, and 2000 calories 
(1.7 gm. protein and 35 calories per kg., reduced one-seventh by the weekly 
fast-days). She was advised this time to take as much open air exercise as pos- 
sible in order to buUd up her strength and relieve her chronic neurasthenia. The 
blood sugar had now come down to normal, so that all tests were normal in all 
respects, and the physical condition was entirely favorable. 

Subsequent History. — The patient remained free from glycosuria and acidosis, 
notwithstanding an attack of tonsillitis in Mar. Normal menstruation returned 
in Apr. In July she again had fever and a grippe-Uke iUness. 

Third Admission. — On account of this she was readmitted on July 13, 1916, 
with definite tonsillitis and temperature of 100.5° F. This cleared up in a few 
days. The general condition was good, and the weight 54.5 kg. A carbohydrate 
test at this time showed a tolerance of 190 gm.; i.e., practically identical with the 
180 gm. half a year before. The patient was discharged on Aug. 15, 1916, weigh- 
ing 52.2 kg., with a prescribed diet of 90 gm. protein, 60 gm. carbohydrate, and 
2300 calories. 

Subsequent History. — ^The urine remained normal. On Aug. 29, the blood sugar 
was 0.2 per cent, the plasma sugar 0.204 per cent, CO2 capacity 65.1 per cent. 
On Sept. 6, the blood sugar was 0.167 per cent, the plasma sugar 0.181 per cent, 
the COa capacity 65.8. 



CASE RECORDS 303 

Fourth Admission.— On Oct. 24, 1916, the patient was again admitted to hos- 
pital because of cold and sore throat. The urine was normal, but a carbohy- 
drate test showed a tolerance of only 130, as compared with the former 190 gm. 
She was again discharged on Dec. 5, 1916, in good physical condition, on a diet of 
75 gm. protein, 30 gm. carbohydrate, and 1750 calories. Her weight was 51.6 
kg. The blood sugar was 0.164 per cent. 

Fifth Admission. — Feb. 20, 1917. The trouble again was tonsillitis with fever. 
There had been increasing tendency to glycosuria following repeated attacks of 
sore throat, and the patient had recently carried out a carbohydrate test in the 
regular manner at home, which showed a tolerance of only 90 gm. carbohydrate. 
A test prior to this had shown a tolerance of only 70 gm. carbohydrate. The 
general condition was still good, but the patient was kept in hospital for some 
time in order to prepare her for tonsillectomy under the most favorable conditions. 
Tonsillectomy was performed under local anesthesia on Mar. 19, 1917, and 
was followed by no glycosuria, acidosis, or complication of any kind. 

The patient was discharged Apr. 6, 1917, on a diet of 50 gm. protein, 10 gm. 
carbohydrate, and 1200 calories, weighing 46.5 kg. 

Subsequent History. — On a low diet, made still lower by weekly fast-days, the 
urine remained normal and the patient felt well except for weakness. There were 
no more sore throats, bm occasional joint pains returned as in the previous 
attacks. 

By May 22, the diet was increased to 55 gm. protein, 10 gm. carbohydrate, 
and 1500 calories. On June 5, it was further increased to 60 gm» protein, 10 
gm. carbohydrate, and 1600 calories. The weight was 46.5 kg. 

On June 19 the blood sugar was 0.161 per cent and the CO2 capacity 61.7 per 
cent. On account of complaints of persistent weakness and recurrent attacks of 
so called rheumatism, the diet was further increased to 75 gm. protein and 1800 
calories (1.6 gm. protein and 38.5 calories per kg.). On July 3, the weight was 
47.3 kg., the blood sugar 0.172 per cent, the CO2 capacity 58.4 per cent. The 
general condition seemed slowly but steadily improving. 

Remarks. — ^This result, 2^ years after the patient was first received on the 
verge of coma, is not bad under the circumstances. Downward progress, though 
not rapid, has been perceptible in the presence of two distinct causes. 

The first to be considered is diet. In the light of later experience a severely 
diabetic patient, aged 21 years, ought not to receive an average ration of 43 cal- 
ories per kg. as prescribed for this patient at the first discharge. One of the 
hopeful features of the earher stage of diabetes is the abiUty to react energetically 
and to carry even unduly high diets with apparent safety for a considerable 
length of time. The most discouraging feature of the later stage resulting from 
these high diets is the apparent breakdown of recuperative power, so that lower 
diets may then spare the weakened assimilation, but can no longer raise it. This 
patient at her first discharge had good flesh and color, but was hindered in earn- 
ing her living by slight neurasthenia and subjective weakness. The familiar 



304 CHAPTER in 

attempt was therefore made to build her up by liberal feeding. For a time she 
displayed the ability, characteristic of this incipient stage, to carry the increase of 
both diet and weight; but the neurasthenia was not cured, nor the recurrent in- 
fections prevented. It is apparent that the high diet had the usual eflfect of low- 
ering the assimilation and weakening the power of recovery. Evidence is seen 
in the marked hyperglycemia on certain occasions between the first and second 
admissions, and in the persistent traces of glycosuria, Dec. 29 to 31, 1915, on diets 
lower than had been tolerated at the close of the first admission. At the second 
admission the blood sugar was kept normal. In contrast to the former 2500 
calories, she was discharged this time on the wiser diet of 2000 calories (30 cal- 
ories per kg. daily average). The third admission was 7 months later, and the 
carbohydrate tolerance test proved that no loss of assimilation had occurred dur- 
ing this interval. The diet -was then raised to 2300 calories. Marked hyper- 
glycemia was found within 2 weeks; and in the interval of only 2 months between 
the third and fourth admissions there was a demonstrated loss of 60 gm. carbo- 
hydrate tolerance. The hyperglycemia at the fourth admission was not over- 
come, and though the diet at discharge was only 1750 calories, traces of glycosuria 
recurred and downward progress accordingly became more rapid. It is the fa- 
miliar story that high diet first fails to accompUsh the intended purpose, and 
subsequently forces the employment of lower diets than would have been proper 
in the first place. 

A second and highly important factor was that of infection. The attacks 
recurred at all periods. The history shows, first, that high feeding did not pre- 
vent the infectious attacks; second, that glycosuria and lowering of tolerance 
from these attacks were most marked when the diet was unsuitable. Even if the 
diet, however, had been perfectly planned, downward progress might still be 
expected from the repeated infections. The comparative safety with which 
operations can be performed with suitable preparation renders them advisable 
in preference to a continuance of the infectious injury. 

CASE NO. 33. 

Female, married, age 51 yrs. Russian Jew; housewife. Admitted Feb. 18' 
1915. 

Family History. — ^Not much known. One sister died of consumption. Pa- 
tient has been married 32 years; had eight children; one died after tonsillectomy; 
others are well. 

Past History. — Patient was bom in Russia. For past 9 years has lived in New 
Jersey in good environment. Healthy life. Measles and typhus in childhood. 
Had nervous breakdown at time of her son's death, and about that time all her 
teeth became loose and were pulled out. During her first pregnancy she appears 
to have had an acute nephritis following a cold; another such attack occurred last 
year. Occasional indigestion and constipation. No alcoholism. Much starch 
and sweets in diet. She has been obese throughout her adult life. 



CASE RECORDS 305 

Present Illness. — Over 2 years ago, because of nervousness, weariness, cold feet, 
headache, and pains in limbs, she consulted a physician and diabetes was diag- 
nosed. Glycosuria cleared up on carbohydrate-free diet; she did not reUsh it and 
lost 25 pounds. Toast was then added to the diet, and later she was allowed even 
cake. She regained 7 pounds weight and glycosuria returned. She was then re- 
stricted to three slices of bread at each meal, but as glycosuria continued, the 
suffering from the above symptoms was so great and continuous that she was 
eager to submit to the most radical treatment if relief were obtainable. 

Physical Examination. — ^Height 130 cm. A short, obese woman without acute 
symptoms. General sensitiveness to touch. Skin of face pits slightly on pres- 
sure. Teeth all false. Throat normal. No lymph node enlargement. Slight 
emphysema. Systolic murmur at heart apex, transmitted to axilla. Blood 
pressure 190 systolic, 100 diastolic. Knee jerks exaggerated. Ankles pit slightly 
on pressure. Faint albuminuria without casts. 

Treatment. — The patient was first placed on a low diet of approximately 52 
gm. protein, 5 gm. carbohydrate, and 750 to 800 calories. With this intake the 
glycosuria on Feb. 18 was 6.1 gm., and on Feb. 19, 5.95 gm. On the first day 
of fasting (Feb. 20) it fell to 1 gm. and after a trace on Feb. 21, cleared up en- 
tirely. For the purpose of reducing the excessive weight, plain fasting was con- 
tinued for 1 week, with only 150 cc. cofifee and 150 cc. soup daily (Feb. 20 to 26). 
On Feb. 27 and 28, nothing but whisky was given (250 to 400 calories), and then 
green vegetables added, containing 12.5 gm. carbohydrate on Mar. 1 and in- 
creasing to 50 gm. carbohydrate on Mar. 6. A fast-day with 300 calories of whisky 
on Mar. 7 cleared up the resultant trace of glycosuria. Eggs and a trifle of crisp 
bacon were then added to the whisky, but the total intake was not above 850 
calories (Mar. 9). The trace of glycosuria which appeared on this day was prob- 
ably attributable to 100 gm. string beans and 150 gm. cabbage, both thrice 
boiled. This glycosuria cleared up on the following day on practically the identi- 
cal diet. After Mar. 12 no more whisky was used, except on the fast-day of 
Mar. 21. On Mar. 12 to 13, a diet of 25 to 40 gm. protein and approximately 
300 calories was tolerated. But on Mar. 14, 68 gm. protein, 9 gm. carbohydrate, 
and 1200 calories caused glycosuria, which continued on the subsequent days with 
reduced caloric intake; the glycosuria was, however, very faint and ceased spon- 
taneously on Mar. 20. The plan was pursued of giving a diet adequate in protein, 
with carbohydrate to the limit of tolerance, but poor in fat and calories. Thus, 
toward the early part of Apr. this diet contained about 120 gm. protein, 20 to 45 
gm. carbohydrate, and 1000 to 1100 calories. Fast-days, sometimes doubled, 
were given almost every week for reducing weight. Toward the close of Apr. 
the patient had become able to assimilate as much as 118 gm. protein, 30 to 50 
gm. carbohydrate, and 2000 calories. She never complained much of hunger 
and was well satisfied on the later diets. 

There was a general gain in clinical condition, but still many complaints of 
headache and pains in abdomen and various parts of body. Weakness and ner- 



306 CHAPTER m 

vousness were also persistent. About the middle of Mar. occurred the first 
menstruation since 8 months before admission to hospital. In Apr. there was 
another menstruation, with undue hemorrhage. Gynecological examination 
failed to reveal fibroids or other cause of hemorrhage, but some abnormality was 
suspected because of the history of a similar trouble in the past. The patient was 
discharged May 8, with the idea of having her reduce her weight further at 
home and find something to divert her attention from her symptoms, which 
were of the sort called neurasthenic. She was well pleased with the improvement 
and could be trusted to continue treatment. 

Acidosis. — ^A salient point is the absence of any threatening symptoms in this 
obese woman during a week of complete fasting without special preparation. The 
ferric chloride reaction, which had been negative, became positive on the low diet 
of Feb. 19 and grew heavy during the fast. Alkali was not employed. The ferric 
chloride reaction subsequently diminished, but was not permanently negative 
during this period in hospital. In the latter part of the stay in hospital the 
ammonia followed a fairly low curve, and the plasma bicarbonate held a low 
normal level. 

Blood Sugar. — There is little to remark except the downward tendency. Evi- 
dently radical measures might have brought it within normal limits rather quickly, 
but in view of the general condition it was deemed preferable to allow the hyper- 
glycemia to be taken care of in the course of long improvement. 

Weight and Nutrition. — The most important therapeutic purpose was to di- 
minish the excessive body weight. The abdomen was very pendulous, and the 
question- arose whether there might not be benefit from a surgical operation which 
should correct the diastasis of the recti and tighten up the abdominal wall, per- 
haps thereby relieving some neurasthenic complaints, and at the same time am- 
putate some 10 or 15 pounds of fat which were sufficiently in the patient's way 
that she would have welcomed surgical relief. It was decided not to venture this, 
but to depend entirely on dietary measures. The weight fell rapidly on fasting, 
and continued to fall on the subsequent diet which conformed to the above men- 
tioned standard of adequate protein, carbohydrate to the limit of tolerance, and 
restriction of fat. The weight at admission was 83 kg., at discharge 70.6 kg.; 
i.e., a loss of 12.4 kg. in 2| months. The discharge diet represented 92 gm. pro- 
tein, 30 gm. carbohydrate, and 1800 calories (approximately 1.3 gm. protein and 
25 calories per kg., reduced one-seventh by the weekly fast-days). As usual, the 
clearing up of diabetic symptoms by reduction of weight had resulted in actual 
gain of strength. In this instance the reduction of the obesity was in itself a reUef 
to the patient. 

Subsequent History. — The presence of a somewhat elevated blood pressure and 
the occasional uterine hemorrhages raised a question in regard to exercise in this 
patient. She was advised to practice walking and to work 3 or 4 hours every day 
in her garden. The urine continued to show negative sugar and slight ferric 
chloride reactions. On June 11, the diet was increased by 50 gm. meat, 2 eggs, 



CASE RECORDS 307 

and 10 gm. carbohydrate. The weight was 70 kg. On July 21, the carbohy- 
drate intake was increased to 50 gm., and at the same time the fat was dimin- 
ished by omitting 25 gm. olive oil. Though the condition in respect to diabetes 
remained uniformly good, the patient's neurasthenia made her a nuisance to a 
devoted family, and she was therefore readmitted to the hospital on Aug. 25 for 
observation. 

Second Admission. — ^The sugar was down to 0.112 per cent in the blood, 0.118 
per cent in the plasma. A slight ferric chloride reaction still persisted. None 
of the organic disorders suggested by the patient's numerous complaints could be 
found. She was again kept on very low diet, the fat being particularly low, the 
protein low but adequate as before, and in this instance the carbohydrate was 
also made low with the idea of maintaining a normal blood sugar. This was 
also the diet prescribed at discharge; namely, 100 gm. protein, 10 gm. carbohy- 
drate, and 1000 to 1100 calories. The patient was now some 7 kg. below the 
weight at her former discharge, and the loss was expected to continue. 

Subsequent History. — The progress was as before. Glycosuria remained absent, 
and on Oct. 6 the ferric chloride reaction was also found negative. Hyperglycemia 
was, however, found to be present after eating, the sugar being 0.156 per cent in 
the whole blood and 0.182 per cent in the plasma. The varied neurasthenic com- 
plaints had diminished but were stiU upsetting the patient herself and her entire 
household. There had been no recurrence of the former uterine hemorrhages, 
and the patient was readmitted to hospital on Oct. U to try more vigorous exercise 
under supervision. 

Third Admission. — The weight was down to 59.2 kg.; i.e., a loss of 24 kg. 
since the first admission. The patient was far stronger and more cheerful. 
Both sugar and ferric chloride reactions were negative. A carbohydrate test 
was now begun in routine manner with a fast-day on Oct. 11, then green vege- 
tables with increase of carbohydrate by 10 gm. daily. A slight ferric chloride 
reaction quickly reappeared and persisted until abolished by increase of carbo- 
hydrate; i.e., with the ingestion of 80 gm. carbohydrate on Oct. 21. The trace 
of glycosuria appearing with the 150 gm. carbohydrate on Oct. 29 was evidently 
accidental, for it disappeared with further increase of the ingestion, and the true 
limit seemed to be reached with 250 gm. carbohydrate Nov. 7 to 13. This assimi- 
lation is in striking contrast to the almost complete absence of tolerance shortly 
after the first admission. One contributing factor in it seemed to be exercise 
(see Chapter V) . The slight glycosuria was cleared up by a fast-day on Nov. 14, 
which promptly brought the high blood sugar of the carbohydrate test down to 
0.119 per cent in the whole blood and 0.125 per cent in the plasma. Thereafter 
a trial was made of a diet of 75 gm. protein, 150 gm. carbohydrate, and 2500 
calories. Persistent traces of glycosuria resulted, evidently from the carbohy- 
drate, inasmuch as the blood sugar curve shows normal values in the morning 
before breakfast. The carbohydrate was therefore diminished to 100 gm., and 
the intake of 2500 calories maintained by substituting fat. The patient was dis- 
charged on Nov. 26, 1915, weighing 55.6 kg., a total loss of 27.4 kg. since her first 



308 CHAPTER in 

admission. Her diet now represented approximately 1.3 gm. protein and 45 calo- 
ries per kg., reduced one-fourteenth by fortnightly fast-days. The exercise had 
been strenuous during this period in hospital, and it proved wholly beneficial. 
She had reached a point where she could walk 8 mUes and climb 40 flights of stairs 
daily in addition to an hour or two of jumping rope and tossing the medicine 
ball. A fairly liberal diet was therefore allowed at the close to maintain strength 
and nutrition and furnish energy for exercise. 

Subsequent History. — On Dec. 13, 1916, the weight was 60 kg., and the patient 
was doing her full housework and walking 5 miles and using a 6 potmd medicine 
ball half an hour daily, with almost complete relief from neurotic troubles. In 
summer, gardening was largely substituted, and she spent 6 hours daily at this 
work. 

On Jime 15, 1916, sugar was 0.141 per cent in the whole blood, 0.185 per cent in 
the plasma; CO2 capacity 63.5 per cent; weight 52 kg. The patient complained 
somewhat of himger, and on July 22 the diet was changed to 100 gm. protein, 50 
gm. carbohydrate, and 2750 calories. On this diet the sugar was 0.159 per cent 
in whole blood, 0.192 per cent in plasma, CO2 capacity 57.9 per cent. Blood 
pressure 130 systolic, 90 diastolic. 

In Sept., the weight was 54 kg. Occasional doubtful traces of glycosuria were 
reported, but on examination at the hospital such reactions were found to be 
false, the slight sediment not representing a true copper reduction. Prog- 
ress has continued in this manner to the present. Neiirasthenic symptoms stiU 
persist to some extent, pain being complained of at different times in head, abdo- 
men, legs, and fingers. The quantity of the diet is fuUy satisfactory. Monot- 
ony is sometimes complained of. Active work is still continued with pleasure, 
and in general the patient is entirely transformed in health and appearance as 
compared with her first admission. 

Remarks. — There are three salient points. First is the good toleration of fast- 
ing by an obese woman without symptoms of acidosis, and the improvement in 
strength with undernutrition. Second is the transformation produced in the 
sugar tolerance by reduction of weight, an increase from practically zero to 250 
gm. Third is the beneficial effect of exercise in a patient apparently showing some 
contraindications. The dangers feared did not materialize, and even the blood 
pressure came down to normal. There is still an abundant supply of body fat, 
but undoubtedly a larger proportion of the weight is now muscle. The neuras- 
thenia was benefited more than the carbohydrate tolerance, and without exercise 
it is doubtful if permanently favorable results could have been achieved. 

CASE NO. 34. 

Male, unmarried, age 26 yrs. Jew; clerk. Admitted Feb. 19, 1915. 

Family History. — Father well at 55. Mother died with diabetes and cardio- 
renal disease at 51. Two brothers and three sisters are well; one brother died in 
infancy; one sister died this year in diabetic coma, aged 19. No knowledge tf 
other heritable disease. 



308 CHAPTER III 

admission. Her diet now represented approximately 1.3 gm. protein and 45 calo- 
ries per kg., reduced one-fourteenth by fortnightly fast-days. The exercise had 
been strenuous during this period in hospital, and it proved whoUy beneficial. 
She had reached a point where she could walk 8 miles and climb 40 flights of stairs 
daily in addition to an hour or two of jumping rope and tossing the medicine 
ball. A fairly liberal diet was therefore allowed at the close to maintain strength 
and nutrition and furnish energy for exercise. 

Subsequent History.— On Dec. 13, 1916, the weight was 60 kg., and the patient 
was doing her fuU housework and walking 5 nules and using a 6 pound medicine 
ball half an hour daily, with almost complete relief from neurotic troubles. In 
summer, gardening was largely substituted, and she spent 6 hours daily at this 
work. 

On June 15, 1916, sugar was 0.141 per cent in the whole blood, 0.185 per cent in 
the plasma; CO2 capacity 63.5 per cent; weight 52 kg. The patient complained 
somewhat of hunger, and on July 22 the diet was changed to 100 gm. protein, 50 
gm. carbohydrate, and 2750 calories. On this diet the sugar was 0.159 per cent 
in whole blood, 0.192 per cent in plasma, CO2 capacity 57.9 per cent. Blood 
pressure 130 systoUc, 90 diastolic. 

In Sept., the weight was 54 kg. Occasional doubtful traces of glycosuria were 
reported, but on examination at the hospital such reactions were found to be 
false, the slight sediment not representing a true copper reduction. Prog- 
ress has continued in this manner to the present. Neurasthenic symptoms still 
persist to some extent, pain being complained of at different times in head, abdo- 
men, legs, and fingers. The quantity of the diet is fuUy satisfactory. Monot- 
ony is sometimes complained of. Active work is stUl continued with pleasure, 
and in general the patient is entirely transformed in health and appearance as 
compared with her first admission. 

Remarks. — There are three saUent points. First is the good toleration of fast- 
ing by an obese woman without symptoms of acidosis, and the improvement in 
strength with undernutrition. Second is the transformation produced in the 
sugar tolerance by reduction of weight, an increase from practically zero to 250 
gm. Third is the beneficial effect of exercise in a patient apparently showing some 
contraindications. The dangers feared did not materialize, and even the blood 
pressure came down to normal. There is still an abxmdant supply of body fat, 
but undoubtedly a larger proportion of the weight is now muscle. The neuras- 
thenia was benefited more than the carbohydrate tolerance, and without exercise 
it is doubtful if permanently favorable results could have been achieved. 

CASE NO. 34. 

Male, immarried, age 26 yrs. Jew; clerk. Admitted Feb. 19, 1915. 

Family History. — Father well at 55. Mother died with diabetes and cardio- 
renal disease at 51. Two brothers and three sisters are well; one brother died in 
infancy; one sister died this year in diabetic coma, aged 19. No knowledge •f 
other heritable disease. 



CASE RECORDS 309 

Past History. — ^Healthy life in fair environment. Measles in childhood, the 
only sickness. Venereal denied. No excesses in alcohol or tobacco. Diet 
moderate without much sweets, but has consisted largely of bread and meat; few 
vegetables. 

Present Illness. — In Nov., 1911, the patient consulted a physician for pains in 
his arms. Local examination revealed nothing, and a liniment was prescribed 
which accomplished nothing. An osteopath was then consulted and gave elec- 
trical treatments without result. In the latter part of 1912 the patient returned 
to the original physician, who this time discovered glycosuria. On carbohydrate- 
free diet plus one slice of Graham bread daily, glycosuria diminished. The 
physician sent the patient to a sanitarium, where he remained 5 weeks. Glyco- 
suria was absent only on green days, but the patient returned home with sugar 
diminished and strength improved. He resumed work as a clerk, but gradually 
became worse, and in 1913 was again sent to the sanitarium. Glycosuria did not 
cease and the result was less favorable. He attempted light work after return- 
ing home, but becoming alarmed by the downward progress, with polyphagia and 
polydipsia, he spent S weeks under the care of Carl von Noorden in the summer 
of 1914. He was free from glycosuria only on 1 fast-day, but felt improved in 
strength on leaving. He resumed light work on carbohydrate-free diet with addi- 
tion of 250 to 300 calories carbohydrate. 

Physical Examination. — ^A well developed young man, thin, but not seriously 
emaciated. No acute symptoms or distress. Flush of cheeks and slight yellow- 
ish color about nasolabial folds. Teeth in good repair; throat slightly congested; 
tonsils not hypertrophied. No palpable lymph node enlargements. Blood 
pressure 110 systolic, 90 diastolic. Knee jerks active. Examination otherwise 
negative. 

Treatment. — On admission, the patient had glycosuria of 6.61 per cent or 
150 gm. in 17 hours, with an intense ferric chloride reaction. There were no 
symptoms suggesting coma, and no hesitancy was felt in instituting carbohy- 
drate-free diet. On Feb. 20 and 21 the diet was 75 to 80 gm. protein, 2 to 3 gm. 
carbohydrate, and 1650 to 1750 calories. The glycosuria fell to 33.2 gm. on 
Feb. 20, and 18.65 gm. on Feb. 21. Fasting was then begun with 500 to 600 
calories of whisky daily. On Feb. 25 the urine was free from sugar and the 
ferric chloride reaction was much diminished. On Feb. 27, green vegetables were 
added to the whisky, and increased to 100 gm. carbohydrate on Mar. 7 to 8. A 
trace of glycosuria then appeared, whUe a slight ferric chloride reaction still 
persisted. After a fast-day with 600 calories whisky on Mar. 9, two eggs and 20 
gm. bacon were added, and increased to a total of 1300 calories on Mar. 11. 
Whisky was then dropped and carbohydrate introduced; but the diet of 91 gm. 
protein, 25 gm. carbohydrate, and 1740 calories on Mar. 13 to IS proved de- 
cidedly in excess of the tolerance. After a fast-day on Mar. 16, a low carbohy- 
drate-free diet was again begun. On Mar. 24, it became possible to introduce 
10 gm. carbohydrate. The diet was then progressively built up until before 



310 CHAPTER ni 

discharge on May 8, it represented 95 gm. protein, SO gm. carbohydrate, and 
2900 calories. The diet prescribed at discharge was 80 gm. protein, 10 gm. car- 
bohydrate, and 2500 calories (nearly 1.6 gm. protein and 50 calories per kg., 
reduced one-seventh by weekly fast-days). The patient looked entirely weU and 
described himself as feeling better than at any time since the onset of diabetes 
He was discharged to rest in the country during the summer. 

Acidosis. — There were no threatening s)rmptoms, either on carbohydrate-free 
diet, or during the initial fast. The carbon dioxide capacity of the plasma was 
slightly below the lower normal level at admission, but rose spontaneously and 
was normal toward the close of the stay in hospital. No alkali was employed at 
any time. The chief signs of acidosis were the ammonia nitrogen of 3.1 gm. at 
admission, and the intense ferric chloride reactions. The ammonia fell rapidly 
to normal values. The beginning of a diet deficient in carbohydrate brought it 
up to 1.4 gm. N on Mar. 12, but later the curve ran lower. The ferric chloride 
reaction gradually diminished and was sometimes negative, but never remained 
so during this hospital period. 

Blood Sugar. — On Mar. 24, without glycosuria, there was nevertheless a fasting 
blood sugar of 0.23 per cent. On Mar. 29, following the preceding fast-day, the 
morning blood sugar was 0.17 per cent. Thereafter the findings were all below 
0.2 per cent. The normal blood sugar on Mar. 3, after the preceding fast-day, 
indicated a downward tendency, and showed that more rigorous treatment could 
easily have maintained a normal level. 

Body Weight. — ^This was 51.6 kg. at admission. The lowest figure, on Mar. 29 
and Apr. 5, was 48.2 kg., representing a loss of 3.4 kg. There was occasional 
slight edema, and particularly during the initial fasting and carbohydrate period 
up to Mar. 8 there was pronounced edema with gain of 0.5 kg. in weight. The 
weight rose on the higher diets in Apr. and May, and at discharge was 51.2 kg.; 
«. e., 0.4 kg. less than at admission. 

Subsequent History. — ^Intelligence and financial circumstances were in the pa- 
tient's favor. He adhered to diet while resting in the country, but on May 18 
showed glycosuria, and as the traces did not clear up he fasted 48 hours. On 
May 25, his urine showed positive sugar and negative ferric chloride reactions. 
The diet was quantitatively reduced, and thereafter glycosuria remained absent 
except for traces appearing at the close of each week and cleared up by the 
routine fast-days. He was therefore readmitted to the hospital on July 28. 

Second Admission. — ^Almost 1 kg. had been gained since the former discharge, 
so that the patient now weighed 0.4 kg. more than at the previous admission. 
The urine was sugar-free but showed a well marked ferric chloride reaction. A 
carbohydrate tolerance test was first instituted. Beginning with a fast-day on 
July 28, 20 gm. carbohydrate in the form of green vegetables were given on July 
29 and increased 20 gm. daily until well marked glycosuria occurred with an in- 
take of 120 gm. After a fast-day on Aug. 5, the diet on Aug. 6 and 7 con- 
sisted of 100 gm. protein, 30 gm. carbohydrate, and 2580 calories. Glycosuria 



CASE RECORDS 311 

resulted; also the ferric chloride reaction, which had become negative during the 
carbohydrate test, returned. A lower diet was then begun, of SO gm. protein, 10 
gm. carbohydrate, and 1300 calories. It became possible to increase the carbohy- 
drate to 20 gm., and the ferric chloride reaction became negative. Sept. 9 to 11 
the patient was at home on this same diet. Sept. 12 was a fast-day. A diet of SO 
gm. protein, 70 gm. carbohydrate, and 1200 to 1400 calories then caused well 
marked glycosuria. The fast-day of Sept. 18 was spent at home. The same 
carbohydrate was given for the following week and strenuous exercise begun. 
Glycosuria remained absent during this week, though the protein was increased 
to 80 gm. and the calories to 2030. Sept. 27 to Oct. 9, a diet of 80 gm. protein, 
100 gm. carbohydrate, and 2130 calories was tolerated without glycosuria. (For 
details of the exercise experiments, see Chapter V.) After the fast-day of Oct. 
10 another carbohydrate test was instituted with heavy exercise. Potatoes and 
other high carbohydrate vegetables had to be used this time to avoid excessive 
bulk. Glycosuria appeared with 210 to 220 gm. carbohydrate on Oct. 28 and 29. 
Exercise was then increased, and glycosuria cleared up and did not return until 
an intake of 270 gm. was reached. 

On Nov. 14, the patient was discharged in apparently excellent health, free 
from glycosuria and ketonuria, on a diet somewhat better balanced than before, 
namely 7S gm. protein, 75 gm. carbohydrate, and 2400 calories (over 1.5 gm. pro- 
tein and 50 calories per kg., reduced by weekly fast-days to 1.3 gm. protein and 
43 calories per kg.). 

Acidosis. — ^The fluctuations shown in the blood bicarbonate were mostly con- 
nected with the exercise, experiments. The ferric chloride reaction cleared up as 
stated when the carbohydrate intake reached 60 gm. on Aug. 1 without other food. 
It remained absent on the fast-day of Aug. 5, but reappeared promptly with the 
subsequent diet. During Aug. it became entirely negative, doubtless on account 
of the low calory diet rather than the introduction of the small quantities of 
carbohydrate. The subsequent occasional traces were perhaps associated with 
the heavy exercise, but continued exercise produced no continuance of this reac- 
tion. Alkali was not used. 

Blood Sugar. — ^There is little to remark except the tendency to slight continuous 
hyperglycemia. Some of the fluctuations stand in connection with the exercise 
experiments. On the high diets allowed it is evident that exercise failed to 
keep the blood sugar below about 0.15 per cent. This accords with other ex- 
perience that it cannot be used as a substitute for caloric restriction. 

Body Weight. — From 52 kg. at entrance, this was reduced to 49 kg. on Aug. 30. 
Thereafter it rose as high as 52.6 kg. on Oct. 10, partly by reason of slight edema. 
The carbohydrate tolerance test in Oct. produced first a sharp fall in weight due 
to undernutrition, followed by a rise to 51.6 kg. due to edema. With subsidence 
of the edema, the long undernutrition (29 days) of this carbohydrate test made 
itself felt by a sharp drop in weight. The patient was discharged weighing 47.4 
kg.; i.e., 4.2 kg. less than at the first admission. 



312 CHAPTER m 

Subsequent History. — ^The patient adhered to diet and exercise, and the urine 
remained normal. The health seemed perfect. On Feb. 10, 1916, sugar in blood 
was 0.141 per cent, in plasma 0.145 per cent, CO2 capacity 65 per cent. Weight 
51 kg. On Feb. 20, the patient slightly overstepped his diet at his brother's 
wedding, and brought on glycosuria which was checked by a fast-day. In Mar. 
he passed through an attack of grippe and bronchitis, and showed traces of 
glycosuria which required temporary reduction of diet. 

Death occurred June 10, 1916. Inquiry elicited the information that there 
had been an attack of acute appendicitis. On account of the diabetes the family 
physician had attempted to avoid operation. Symptoms of perforation appeared 
on June 5, and glycosuria had also developed. On that day the patient was rushed 
to a hospital for an emergency operation. Anesthesia was given with nitrous 
oxide and oxygen. Perforation of the appendix and free peritonitis were found. 
Following operation he seemed to do well and became free from glycosuria. The 
diet during this time was not stated. On June 9, coma was said to have devel- 
oped in spite of alkali treatment and resulted in death the next day. 

Remarks. — Undernutrition had the usual effect in raising tolerance, relieving 
symptoms, and improving strength. The diet toward the close of the first period 
in hospital was unduly high. The condition then, with sugar-free urine, rising 
weight, and only a trace of ferric chloride reaction and slight hjrperglycemia, was 
one ordinarily considered highly favorable in a case of this type and was clearly 
superior to the results achieved by specialists who had treated this patient at 
earlier and milder stages of his condition. But the return of glycosuria whUe the 
patient was under favorable environment at home and adhering faithfully to 
treatment was not accidental nor an indication of spontaneous downward prog- 
ress, but was the inevitable result of the high diet which was producing the gain 
in weight. A stUl more favorable condition was achieved during the period of 
undernutrition in the first half of the second stay in hospital. The diet was then 
increased to a less degree than before, and at the same time heavy exercise was 
employed to use up the surplus calories and if possible buUd up the assimilation. 
The effect upon both the tolerance and the general health was clearly beneficial 
and no ill results were observed. Nevertheless, exercise could not entirely re- 
place caloric restriction, for hyperglycemia was persistent, whereas with exercise 
and a lower diet the blood sugar might have been normal. The ultimate outcome 
in this type of case probably could not have been favorable on a diet as high as 
that allowed. The observation upon this patient was interrupted by the im- 
timely death from a cause bearing no definite relation to the diabetes. A note- 
worthy point is that the patient was on liberal diet, so that he was steadUy gain- 
ing weight; otherwise critics might allege that susceptibility to such an accident 
was due to undernutrition. It so happens that the majority of serious infec- 
tions and accidents in this series have happened to patients on high rather than to 
those on low nutrition. It is possible that suitable dietetic care before and after 
operation might have prevented the fatal result. 



CASE RECORDS 313 

CASE NO. 35. 

Male, married, age 61 yrs. American; lawyer. Admitted Feb. 20, 1915. 

Family History. — Mother died of typhoid at 32, father of some paralytic con- 
dition at 57. Three sisters and two brothers are well; one other brother has 
arthritis. A first cousin died of cancer. No other heritable disease known. 
Patient has been married 34 years; wife healthy but never pregnant. 

Past History. — Healthy life under excellent hygienic conditions. Grippe, 
measles, whooping-cough, and mumps in childhood. Probably mild typhoid at 
13. A few attacks of grippe since. No sore throats or other minor infections. 
No venereal disease. Habits very regular and simple. No alcohol used until 
prescribed for diabetes. No excesses in diet or indulgence in sweets. Bowels 
regular. No nerve strain. Patient has been a prosperous lawyer and official in 
a small New York cityunder seemingly ideal conditions of health. 

Present Illness. — 11 years ago persistent backache was the first symptom. 
Within a year thereafter more or less polyuria was noticed. Glycosuria was then 
found, but ceased with simple abstinence from bread and potatoes. During the 
ensuing year, however, glycosuria became more stubborn and 20 pounds weight 
were lost. 9 years ago, on his physician's advice, the patient spent 30 days under 
the care of Carl von Noorden. He received the usual treatment with green days, 
oatmeal days, etc. , and was told that it was impossible for him to be free from 
glycosuria. He returned with glycosuria diminished and strength increased, 
with a gain of 5 pounds in weight. He adhered for 1| years to the diet pre- 
scribed in Vienna, which contained liberal amounts of carbohydrate. 10 pounds 
weight were lost. He then returned to Vienna for 33 days of treatment. He 
again gained 5 pounds and felt better. The glycosuria was stUl present on 
leaving. He again followed the prescribed diet until 1909, when he returned to 
von Noorden for 31 days. This time the trouble was more persistent and there 
was little improvement. The patient still carried on his regular work. In 1911 
he was treated by von Noorden for 33 days with more stringent measures than 
before, 2 fast-days being employed. He continued in sKghtly reduced health 
until Apr., 1914, when a buU knocked him down and broke four ribs. Dangerous 
acidosis came on. His medical advisor knew of the fasting treatment, and 
withheld aU food for 4 days. The symptoms of impending coma passed off. 
Since then he has remained subjectively in tolerable health, and came for treat- 
ment only because his physician advised that the persistent glycosuria and acidosis 
should be cleared up if possible. 

Physical Examination. — Height 170 cm. A well developed, adequately nour- 
ished, unusually rugged looking man for his age. No aCute symptoms, but a 
marked odor of acetone. Mouth and throat normal. Only insignificant lymph 
node enlargements. Blood pressure 120 systolic, 80 diastolic. Liver edge pal- 
pable 4 cm. below costal margin in mammary Hne. Knee jerks obtained only 
slightly with reinforcement. Ankle jerks sluggish. General examination is that 
of an unusually healthy man. 



314 CHAPTER in 

Treatment.— Oa the first full days in hospital, Feb. 21 and 22, the patient re- 
ceived an observation diet of 95 to 130 gm. protein, 5 to 8 gm. carbohydrate, and 
1900 to 2000 calories, and excreted 25 to 22 gm. sugar, with evidently consider- 
able diacetic acid. Beginning Feb. 23 he was given an 8 day fast, with 150 to 
200 cc. whisky, 300 cc. soup, and 300 cc. coffee daily; no alkaU. The glycosuria 
diminished, but the ferric chloride reaction became intense; the carbon dioxide ca- 
pacity of the plasma remained approximately normal. The patient began to com- 
plain of malaise and nausea, and appeared drowsy. On Mar. 2 he vomited. 10 gm. 
sodium bicarbonate on this day failed to alter the symptoms. Therefore on Mar. 
3 the fast was broken off, and a diet of 48 gm. protein, 5 gm. carbohydrate, and 
1300 calories was given. This was increased on the following days, so that on 
Mar. 10 the intake was 90 gm. protein, 5 gm. carbohydrate, and 2450 calories. 
30 gm. sodium bicarbonate were given on Mar. 3, and the. same on Mar. 4. The 
ketonuria continued heavy and the glycosuria increased, but not to anything 
hke the previous figure. Mar. 12 to 16 the diet was strictly carbohydrate-free. 
The symptoms which had developed on fasting had disappeared immediately on 
feeding, and the patient remained entirely comfortable on carbohydrate-free 
diet. Mar. 17 fasting was resumed with whisky, soup, and coffee as before. 
The glycosuria promptly fell to traces. Alkali was not given. On Mar. 17 the 
patient was subjectively comfortable. On Mar. 18 he complained of slight 
nausea. Therefore, without waiting for absolute freedom from glycosuria, on 
Mar. 19 the 630 calories of alcohol were augmented with an egg, 25 gm. bacon, 
and 250 gm. thrice boiled vegetables. The clinical symptoms were thus re- 
lieved, and the glycosuria also cleared up on Mar. 20, while the ferric chloride 
reaction was diminished. Traces of glycosuria returned on certain of the ensuing 
days. Another single fast-day withwhisky, soup, and coffee was given on Mar. 28. 
The protein-fat diet was gradually buUt up, until on Apr. 2 and 3 it represented 
72 to 82 gm. protein and 1750 calories, nearly half of which was alcohol. As 
symptoms of danger were apparently past, it became feasible to proceed to raise 
the tolerance and attack the persisting acidosis. Therefore Apr. 4 was a fast- 
day with 700 calories of whisky. On the following 2 days, 10 gm. carbohydrate 
were added to the whisky. On Apr. 7 whisky was diminished, and thereafter 
discontinued. A routine carbohydrate test (Apr. 8 to 17) established the toler- 
ance as about 100 gm. carbohydrate. At the same time the ferric chloride reac- 
tion became much paler. A diet was then begun with inclusion of 15 gm. carbo- 
hydrate. Traces of glycosuria were too frequent, and on May 12 to 14 the 
patient fasted 3 days; nothing but 300 cc. coffee and 300 cc. soup daily was given. 
Undernutrition was then continued, with persistent low diet and a routine fast- 
day every week. After the fast-day of May 23, glycosuria was permanently 
absent, but shght ferric chloride reactions continued. The patient was dis- 
charged June 22, on a diet of 78 gm. protein, 15 gm. carbohydrate, and 2120 cal- 
ories (slightly less than 1.5 gm. protein and 40 calories per kg., diminished 
one-seventh by the weekly fast-days). He had become accustomed to the simple 



CASE RECORDS 315 

low diet, and could be depended upon to continue it accurately at home. The 
general appearance was distinctly not so good as at admission; but in addition to 
the altered laboratory findings, the patient insisted that he felt better and his 
mind was clearer than before. 

Acidosis. — ^The case illustrates the difficulties and possible danger of fasting 
sometimes in long standing diabetes, when the patient perhaps appears in very 
favorable condition. This patient had previously undergone fasting with benefit 
after the accident with the bull. His physician considered that at that tmie the 
fasting saved him from dying in coma. On the present occasion in hospital he 
showed no symptoms either on mixed diet or on the change to carbohydrate-free 
diet. But toward the close of an 8 day fast the typical warning symptoms de- 
veloped, and were not prevented by the rather hberal use of whisky, nor relieved 
by 10 gm. sodium bicarbonate. The carbon dioxide capacity of the plasma at 
this time was within normal Umits and gave no warning of the critical condition, 
which was recognized by cUnical symptoms alone. As usual when this condition is 
taken in time, feeding cleared up the symptoms immediately. Other experience 
confirms the view that the use of soda was not essential, nor was it necessary to 
give carbohydrate. The mere giving of food, even though this consisted chiefly of 
fat, was sufficient to reUeve the intoxication of this fasting acidosis. Also as usual 
in such cases, the sensitiveness disappeared later, so that modifications of diet 
were made at will without clinical disturbance. Corresponding to the normal 
blood alkalinity, the ammonia nitrogen was never above 2 gm. It diminished, 
but did not reach normal limits until the carbohydrate tolerance test in Apr. 
The intense ferric chloride reaction was the only laboratory index which corre- 
sponded to the cUnical intoxication, yet this remained equally intense when 
carbohydrate-free diet had cleared up the chnical symptoms completely. This 
reaction gradually faded out, but did not become permanently negative during 
this period in hospital. 

Blood Sugar. — The only normal blood sugar was 0.108 per cent in both whole 
blood and plasma on the morning of June 14, following the preceding fast-day. 
The persistent hyperglycemia was the reason for the rigorous undernutrition 
period (May 11 to IS) comprising 2 days of very low diet and 3 fast-days. This 
entirely failed to reduce the hyperglycemia, which was 0.2 per cent on May 15. 
The treatment had been rigorous, and it was deemed advisable not to push 
undernutrition further in an attempt at a rapid reduction of such a stubborn hy- 
perglycemia, but rather to leave it, hke the ferric chloride reaction, to take care 
of itself in the course of gradual improvement. 

Weight and Nutrition. — The patient was received appearing in unusually robust 
health for his age, weighing 66.4 kg. At discharge his weight was 54 kg.; i.e., 
a loss of 12.4 kg. in consequence of the' undernutrition treatment. The only 
tangible sign of improvement was from the laboratory side. He claimed to feel 
such benefit subjectively that he was firm in continuing treatment, but his ap- 
pearance was noticeably thin and haggard, compared to that on admission. The 



316 CHAPTER III 

diet at discharge was sufficiently liberal that he could be expected to hold weight 
or perhaps gain sHghtly. 

Subsequent History. — Glycosuria remained absent, and by the end of July the 
ferric chloride reaction had become negative. On Aug. 21, his local physician 
(not the consultant who had sent him to the hospital) called at the Institute to 
report that the patient's family and friends were worried about him, and that 
although he was doing his work after a fashion, his working power and apparent 
strength were not equal to what they were before treatment. Information was 
otherwise obtained that the home opinion of the effect of the treatment was de- 
cidedly unfavorable, and only the loyalty of the patient himself and his medical 
consultant kept him strictly to the program. His local physician was assured 
that a considerable period of subnormal weight and strength was unavoidable, 
and the results would appear later. With continued diet and exercise the progress 
continued favorable. On Oct. 13, 1915, the sugar in whole blood was 0.178 per 
cent, in plasma 0.185 per cent. The weight was 57.4 kg. An increase of car- 
bohydrate to 25 gm. was permitted. Steady and obvious improvement continued, 
and the patient reentered the hospital Feb. 5, 1917, on request for observation, 
having never shown glycosuria since discharge. 

Second Admission. — ^The weight was 61.6 kg.; i.e., 7.6 kg. more than at dis- 
charge, but 5.2 kg. less than at the first admission. The urine was negative for 
both sugar and diacetic acid. Following the fast-day of Feb. 6, the blood sugar 
on the morning of Feb. 7 was 0.115 per cent. A carbohydrate test ending Feb. 
26 showed a tolerance of 240 gm. carbohydrate, as compared with the 100 gm. 
in the previous Apr. Chiefly by the undernutrition in the carbohydrate test the 
weight was reduced, and was 57.2 kg. at discharge on Mar. 3. The mixed diet 
of Feb. 29 to Mar. 3 contained 50 gm. carbohydrate. The diet prescribed at 
discharge consisted of 100 gm. protein, 35 to 40 gm. carbohydrate, and 2500 
calories. 

Remarks. — ^The case illustrates the feasibility and desirabiUty of effective 
treatment even in long-standing cases of diabetes in advanced Ufe. Probably no 
diabetic of 61 years could appear more healthy and less injured by glycosuria 
than this patient, according to superficial appearances at his first admission. 
There was a serious question whether it was worth while to undertake to clear up 
the condition. This was done partly on advice of Dr. S. J. Meltzer, who urged 
that the patient might at any time meet some accident and go into coma, or de- 
velop gangrene and die from it. The known difficulties of such cases were 
encountered; namely, first, the serious symptoms during fasting, and second, 
the period of several months of lowered weight and impaired strength from 
undernutrition. Not only, however, was relief from diabetic symptoms and the 
attendant dangers ultimately achieved, but also the physical condition even at a 
sUghtly reduced weight came back to a decidedly better state than before treat- 
ment. The patient could think better, work better, and enjoy life more than 
at any time since the first onset of his diabetes, and the objective evidences were 
such that his family and neighbors were fully convinced. 



CASE RECORDS 317 

The primary treatment of such a case is fully as difficult as that of young 
patients. In a case of this severity, halfway measures are wholly inadequate and 
often injurious. The ultimate prognosis is undoubtedly better than in younger 
patients. The slow improvement may be expected to continue, so that further 
relaxation of diet and increase of weight may be expected. Barring accidents, 
there should be no further trouble from the diabetes. 

CASE NO. 36. 

Male, unmarried, age 30 yrs. American; electrical engineer. Admitted Mar. 
8, 1915. 

Family History. — Father died of Bright's disease 5 years ago. Mother aUve, 
has myxedema. Three sisters are well. One brother died of diphtheria at 4 
years. Another died of diabetes at the age of IS. 13 years ago a paternal first 
cousin died of diabetes at 16. No tuberculosis, cancer, syphilis, or nervous dis- 
orders known in family. 

Past History. — Healthy life, mostly spent in Canada, always under excellent 
hygienic conditions. Measles and diphtheria in childhood. A large peritonsillar 
abscess at 27 years, which lasted 2 weeks and caused fever and obstruction of 
breathing. 

Present Illness. — During 1913, trouble occurred with a wisdom tooth, resulting 
in an abscess, and a dentist in several attempts was tmable to extract it. Thirst, 
polyuria, and loss of weight were noticed shortly thereafter. In Jan., 1914, the 
diagnosis of diabetes was made in Toronto. He was in hospital 10 days under 
dietetic treatment, when another abscess developed about the same wisdom 
tooth. This was extracted after 3 days, but necrosis of the jaw and septicemia 
ensued. There was fever and delirium, and more or less infection persisted until 
the end of Apr. From his normal weight of 140 pounds he declined to 90 pounds, 
but during May came back to 130 pounds. At the end of May there was an 
attack of acute appendicitis with pain and fever for 2 days. Another attack came 
on July 28, and appendectomy was performed on July 30. There was a colon 
bacillus infection of the wound, which did not heal untU Sept., 1914. Meanwhile 
there were three abscesses in the neck, treated by vaccine; the last one did not 
heal until Oct. The weight was now down to 115 pounds. The patient dragged 
along with glycosuria and diminished weight and strength, but was not bed-fast, 
until the time of admission to this hospital. 

Physical Examination. — ^A well developed, moderately emaciated young man 
with no urgent symptoms. Acute coryza present.- Teeth in good repair except 
lower left third molar, of which only the root is present. Throat normal; no 
tonsillar hypertrophy or exudate. Very slight enlargement of superficial lymph 
nodes. Blood pressure 100 systolic, 60 diastolic. Reflexes normal. General 
examination negative. 

Treatment. — The observation diet on Mar. 9 and 10 consisted of 75 to 80 gm. 
protein, 3 gm. carbohydrate, and 1670 to 2300 calories. On Mar. 10, the sugar 



318 CHAPTER ni 

excretion was 14.6 gm., the ammonia nitrogen 2.25 gm., and the ferric chloride 
reaction intense. 4 days of fasting with whisky cleared up the glycosuria and 
diminished the ferric chloride reaction and the ammonia output. Green vege- 
tables were then begun, 20 gm. carbohydrate being thus added to the whisky on 
Mar. IS, after which whisky was stopped. Increase of vegetables in the form of a 
carbohydrate test established the tolerance as 175 gm. carbohydrate, this "quantity 
being tolerated on Apr. 3, but causing slight glycosuria on Apr. 4. A mixed diet 
was then rather rapidly built up, with the usual weekly fast-days. At dis- 
charge on July 15 the diet consisted of 80 to 90 gm. protein, 50 gm. carbohydrate, 
and 2500 calories (1.6 to 1.8 gm. protein and 50 calories per kg., diminished one- 
seventh by weekly fast-days). The only special incident in hospital was the re- 
moval of the root of the left lower third molar tooth on Apr. 28, after a rather 
difficult half hour operation under local anesthesia. Glycosuria followed this 
operation, though it will be noticed that both carbohydrate and total diet were 
less than had been tolerated on former days. The slight glycosuria ceased with 
a single fast-day on Apr. 29, and there was no further trouble. The patient at 
discharge was not up to full normal strength, but was improved to the point 
where he felt able to undertake light work. 

Acidosis. — ^This was never threatening, and the carbon dioxide capacity of the 
plasma remained normal. The ferric chloride reaction was not negative for any 
considerable period except during the carbohydrate tolerance test. Mar. 24 to 
Apr. 5. The persistence of this reaction, though slight, was one indication of the 
need of more thorough treatment in a patient of this type. 

Blood Sugar. — ^In conformity with the rule that glycosuria or hyperglycemia 
resulting from carbohydrate alone is brief, the blood sugar on the morning of 
Apr. 1 was 0.11 per cent notwithstanding the large carbohydrate ration. The 
normal figure on Apr. 30, following the single extra fast-day of Apr. 29, shows how 
easily hyperglycemia might have been abolished. The actual tendency of the 
curve, as far as analyses were made, was progressively upward. Traces of gly- 
cosuria also became more frequent toward the close. These points confirmed the 
indication of the ferric chloride reactions, that the tolerance was being slightly 
overtaxed. 

Weight and Nutrition. — Slight undernutrition was practiced at first, then lib- 
eral diets allowed, and the weight at discharge was almost exactly identical with 
that at admission. The patient was over-eager for quick results. He com- 
plained of hunger on slight restrictions, and found fast-days very hard. His 
neurotic temperament was one excuse for the attempt to feed with a view to 
maintaining the highest possible weight and strength. 

Subsequent History. — Sugar remained absent and the ferric chloride reaction 
slight. On July 27, an increase of carbohydrate to 60 gm. was permitted. In 
Aug. the patient reported having found congenial light work, and as sugar was 
still absent the carbohydrate ration was increased to 75 gm. Glycosuria remained 
completely absent except for one trace in Nov. from an unintentional mistake in 



CASE RECORDS 319 

diet, and another in Dec. from nervousness (on the usual basis of dietary hyper- 
glycemia). After Christmas, 1915, he stopped weighing food and became interested 
in Christian Science. He began to add cautiously to his diet, and whenever 
sugar appeared was frightened out of his trust in Christian Science and fasted 
sufficiently to clear it up temporarily. In May, 1915 he began to disregard diet 
and urinary tests altogether. The rapid loss of weight and strength convinced 
him of his mistake, but he did not report to the Institute. He was at a mineral 
water resort for a short time, and became so weak that he had to telegraph his 
sister to assist him home. He arrived in New York on June 6 with indigestion, 
and was obliged to fast almost completely from inability to take food, until 
readmitted to the hospital on June 9. 

Second Admission. — Emaciation had brought the weight down to 42.2 kg. 
The patient was semistuporous, bordering on coma. Knee and Achilles jerks were 
normal. June 10, the first full day in hospital, on a carbohydrate-free diet of 
63.5 gm. proteia and 1450 calories, he excreted 68 gm. glucose and 4.55 gm. am- 
monia nitrogen, with urinary acidity of 611 cc. n/10 (Folin). The ferric chloride 
test was black, the CO2 capacity of the plasma 30.3 vol. per cent, the sugar in whole 
blood 0.270 per cent and in plasma 0.385 per cent. The plasma during the entire 
former period in hospital had been clear; it now appeared like cream, and showed 
8.2 per cent fat. The feeding of June 9 and 10 had been employed because of the 
possibility that coma symptoms had resulted from fasting. Feeding did not 
clear up the symptoms. On the contrary, on June 10 the ammonia was higher 
and the CO2 capacity lower than at admission the day before, and the clinical 
condition appeared more critical. Accordingly, absolute fasting was begiin June 
11, with nothing but 450 cc. coffee and 550 cc. clear soup daily; no alcohol and 
no alkali. The fluid intake was not forced; the patient was merely encouraged to 
drink rather freely, and actually took only 2500 to 2800 cc. total fluids daily. 9 
days of absolute fasting diminished the lipemia to 4 per cent, the ammonia to 
1.34 gm. N, the urinary acidity (Folin) to 230 cc. n/10, and the glycosuria to 
5.88 gm. The CO2 capacity of the plasma rose with equal steepness to normal 
limits. The hyperglycemia showed one of the peculiarities sometimes observed 
in fasting; for after the sugar had gone down to 0.25 per cent in the whole blood 
and 0.3 per cent in the plasma, it suddenly rose to 0.38 per cent on June 14, and 
was still 0.325 per cent on June 16, though the glycosuria had greatly diminished. 
All symptoms of danger had cleared up in the early days of fasting. Though the 
patient was not dangerously weak, it was deemed expedient to interrupt the long 
fast by a few days of low diet. Accordingly, on June 20, 35 gm. protein and 683 
calories were given, and on June 21 to 23, SO gm. protein and 1000 calories daily. 
The glycosuria increased, the blood sugar rose from 0.2 to 0.28 per cent, the 
ammonia excretion increased slightly, and the plasma bicarbonate fell from 58.6 
to 55.4 per cent. Fasting was resumed June 24 to 27, thus making 13 fast-days 
in all. Glycosuria ceased, the ferric chloride reaction became negative, the am- 
monia fell low, the CO2 capacity reached its highest point, and sugar in both blood 



320 CHAPTER m 

and plasma dropped to 0.2 per cent. The ensuing carbohydrate test revealei 
a tolerance of not over 70 gm. carbohydrate in green vegetables. In this test th^ 
ammonia reached its lowest level. After the fast-day of July 9, mixed diet wa 
begun, consisting first of 72 gm. protefn, 5 gm. carbohydrate, and 1450 calories 
increased on July 24 to 85 gm. protein, 15 gm. carbohydrate, and 1700 calories 
The urine was now normal, and the patient, though not so strong as at his forme 
discharge, felt able to do Ught work, and was discharged on July 26 on the las 
mentioned diet, with addition of 3 bran muffins and 400 gm. thrice boiled vege 
tables. 

Acidosis. — ^The sahent point is that both the clinical and laboratory signs o 
very imminent coma were cleared up promptly and completely by fasting withoui 
alcohol or alkali. Presumably alcohol would have accomplished nothing unlesi 
to maintain strength. Soda might have been given if the blood alkalinity hac 
not risen spontaneously. No cUnical tendency to acidosis was left behind. Th( 
CO2 capacity remained fully normal. The ferric chloride reaction cleared ui 
completely during the second fast and remained negative. The ammonia fel 
steeply during both fasts, reached its lowest level during the carbohydrate test, anc 
rose as high as 0.8 to 1.1 gm. N on the subsequent mixed diet, it being at this time 
the sole indication of sUght acidosis. It is noteworthy that even though the dia- 
betes was clearly worse than at the former admission and the carbohydrate in the 
diet so much less, the markedly low diet as respects fat and calories now pre- 
vented the excretion of diacetic acid which was almost constantly present during 
the former period in hospital. 

Blood Sugar. — ^The peculiarities during fasting were mentioned above. On the 
carbohydrate test the fasting blood sugar remained stationary at 0.2 per cent; 
the plasma sugar rose to 0.228 per cent. On mixed diet the tendency of the 
blood sugar was downward, the normal value on July 24, following the fast-day 
of July 23, showing that the hyperglycemia was still readily capable of control by 
a low caloric diet. The sUght increase in diet at discharge brought a return oi 
moderate hyperglycemia. 

Body Weight. — ^The difference between loss of weight produced by underfeed- 
ing for therapeutic benefit and the injurious emaciation resulting from unchecked 
diabetes is exemplified. 

This brief period in hospital gives an unusually striking illustration of the 
possible fluctuations in water content of the tissues of diabetics, as shown by the 
contour of the weight curve. As usual it fell slightly during the first days of fast- 
ing. The slight rise due to edema toward the close of the fast is not uncommon, 
The unique feature is the continued steep ascent on the low protein-fat diet oi 
June 20 to 23. It reached 50 kg. and remained there during the 4 day fast: 
i.e., a gain of 8.4 kg. in the week June 16 to 24. The edema was so intense 
that there were pressure pains in the legs. It was presumably of renal (no albu- 
min or casts) or obscure metabolic origin, possibly standing in some relation with 
the pecuUar leap of the blood sugar, and evidently associated with chloride reten- 



CASE EECOEDS 321 

tion, for salt-free diet brought a fall almost as rapid as the rise. Though the 
diet beginning June 10 was low, the weight rose again without visible edema. 
The increase (45.7 kg. at discharge as compared with 42.2 kg. at admission) 
probably represents largely water retention by tissues formerly abnormally 
dried. 

Undernutrition. — The following calculation can be made for 46 days of the 
second hospital period (June 9 to July 25) : 



46 days. 



Per day 
(average). 



Protein in diet 1,535 .2 gm. 

Nitrogen"" 245.6 " 

Total nitrogen excreted 334.64 " 

Nitrogen deficit (output — intake) 89 . 04 " 

Total calories in diet 29,737 



33.4 gm. 
5.34 " 
7.27 " 
1.93 " 
647 



Subsequent History. — On Aug. 23 the patient reported that he was feeling con- 
stantly better. The urine was uniformly negative for both sugar and ferric 
chloride reactions. The sugar in whole blood was 0.117 per cent, in plasma 
0.128 per cent, CO2 capacity 51.8 per cent. Weight 46.8 kg. An increase of S 
gm. carbohydrate was permitted and tolerated. In Sept. an increase of fat, so 
as to make the total calories 1830, was permitted. The weight was then 48 kg. 
The patient was at work and professed himself contented with his condition and 
diet. On Nov. 26, a letter was received expressing deep gratitude, and stating 
that he had followed diet but wished to relieve himself of his former pledge; 
though he intended to make no radical changes, he nevertheless proposed to fol- 
low his own discretion. The next report received was a telegram on Feb. 2, 
1917, announcing that the patient had died at 8 o'clock that day. 

Remarks. — The case presents two possible etiologic factors; namely, heredity 
and infection. Diets to the verge of tolerance were permitted, partly because 
of the unstable temperament, but largely because their injurious effects were 
not properly understood. They were fairly well borne for a munber of months 
as usual, but did not serve to prevent the patient from breaking treatment. 
They perhaps did more harm than the record indicates. It seems possible that 
on the basis of a mild or moderate inherited tendency, active diabetes had been 
developed and maintained by a series of acute infections. With the clearing up 
of the infections and of diabetic symptoms there was seemingly a marked ten- 
dency to improvement, as indicated by the rapidly acquired tolerance for high 
diets. Possibly under sufficiently careful treatment the diabetes might to some 
extent have become latent. The tendency to improvement was probably crippled 
by the high diets employed. It is certain that seemingly brilliant success often 
masks irreparable injury. After months or years of overdriven function a per- 
manent and hopeless lowering of assimilation is found, which is blamed upon 
"spontaneous downward progress." In this instance the actual disaster was 
precipitated by Christian Science; but in any case with acute infectious etiology, 



322 CHAPTER m 

there is always the possibility that early thorough relief of dietary strain may per- 
mit a degree of recovery sufficient to protect against such a misfortune. 

On the second admission to the hospital the patient had learned a severe lesson 
and was amenable to discipline. The results show that although his case had 
become more severe, it was stiU readily controlled by radical treatment, and on 
better treatment than before the laboratory findings were somewhat better, 
though the weight and strength were less. After discharge the tendency to a 
slow recovery of tolerance and weight was still manifest. This time New Thought 
literature overcame the patient's fears, when he began to feel like himself once 
more. He was of the neurotic nature predisposed to such aberrations, and they 
were responsible for his death. 

CASE NO. 37. 

Male, unmarried, age 16 yrs. American; liigh school student. Admitted 
Mar. 19, 1915. 

Family History. — Mother, father, two brothers, and one sister well. No special 
disease in family. 

Past History. — Healthy life under excellent conditions in New York City. 
Measles and chicken-pox in infancy. No venereal or other diseases. Never 
used alcohol or tobacco. No excesses in diet. Up to 2 years ago his family com- 
plained that he did not eat enough. Since then he has been "always ready to 
eat." Has the usual appetite for candy, but has not taken naore sweets than 
most boys. Never nervous or overstudious. Has been content to stand about 
the middle of his class, has taken part in athletics and is now captain of the 
basket-ball team of his high school. Lately he has had toothache, and just 
before admission to hospital an abscess about one molar. 

Present Illness.^S weeks before admission patient caught a severe cold in 
connection with, a hard game of basket-ball. The following day he felt consid- 
erable thirst, which he attributed to the fever accompanying the cold. Poly^ 
dipsia and polyuria continued, and his family noticed a lack of energy. The 
symptoms progressed until, about a week ago, he was drinking water and pass- 
ing urine approximately every 40 minutes. Appetite seemed to be unchanged. 
He has been sleepy the past few days. The family physician, who was then 
called, made an immediate diagnosis of diabetes, gave sodium bicarbonate, and 
advised coming to this hospital. The patient came unaccompanied, merely for 
examination. The signs of impending coma were such that he was put to bed 
immediately and his family notified. 

Physical Examination. — A well developed, firm muscled boy, looking perfectly 
healthy except for the unnatural flush of the cheeks, noticeable dyspnea, odor of 
acetone, and marked sleepiness. Tongue red and slightly coated. Teeth show 
considerable caries and slight pyorrhea. Throat, congested; tonsils enlarged to 
olive size. Small lymph nodes palpable in cervical, axillary, epitrochlear, and 
inguinal regions. Knee and other reflexes active. Blood pressure 120 systolic, 
90 diastolic. Examination otherwise negative. 



CASE RECORDS 323 

Treatment.— ^Ovfing to the urgent symptopis, fasting was begun immediately. 
The urine from 5 p.m., the hour of admission, to 7 a.m. showed 71.3 gm. sugar and 
intense ferric chloride reaction. The carbon dioxide capacity of the plasma 
was 25 vol. per cent at admission. 10 gm. sodium bicarbonate and 70 cc. whisky 
were given during the night. Mar. 20, the dosage was 30 gm. bicarbonate and 
160 cc. whisky da,ily. By this time the threatening clinical symptoms had 
passed off. Mar. 22, the bicarbonate was diminished to 10 gm., and then dis- 
continued. Whisky was not used after Mar. 24. Glycosuria was absent on 
Mar. 27, the ferric chloride reaction was slight, the carbon dioxide capacity of 
the plasma was approxirnately normal, and the ammonia 'nitrogen, which on 
Mar., 20 was 5.62 gm., had fallen to 0.73 gm. The blood sugar, which was 0.21 
per cent at admission, fell steadily to 0.1 per cent on Mar. 31, On Mar. 29, 10 
gm. carbohydrate in the form of green vegetables were given, and increased rather 
rapidly. On Apr. 12 to 14, 175 gm. daily were assimilated, but the increase to 
200 gm. carbohydrate on Apr. 15 brought slight glycosuria. After the fast-day 
of Apr- 16, eggs, bacon, and vegetables were allowed on Apr. 17, representing 
33 gm. protein, 15 gm. carbohydrate, and 770 calories. Slight glycosuria re- 
sulted, as sometimes happens with a diet following a fast-day. This cleared up, 
and higher diets were quickly tolerated with only bare traces of glycosuria. From 
the latter, part of May to Aug., the diets were about 2500 calories, comprising 
90 to 100 gm. protein and increasing carbohydrate up to 205 gm. On July 31, 
after the fast-day on Aug. 1, another tolerance test was instituted, and in order 
to give the requisite quantities of carbohydrate it was necessary to include such 
foods as potatoes, corn, lima beans, peaches, and bananas. On Aug. 6, 400 gm. 
carbohydrate with 83 gm. vegetable protein were assimilated. Glycosuria oc- 
curred on Aug. 7 with 500 gm. carbohydrate and 118 gm. vegetable protein. 
The glycosuria ceased with a green day on Aug. 8, representing 24 gm. protein 
and 103 gm. carbohydrate. The patient was disniissed Aug. 11 on a diet of 100 
gm. protein, 100 gm. carbohydrate, and 2450 calories. He looked and felt 
entirely well and was permitted to resume school work. The only special inci- 
dent in hospital was the necessary dental work to bring his mouth into good con- 
dition, including the extraction of three molar teeth, which was done without 
ill effects. 

Acidosis.— The clearing up of the various signs of impending coma on fasting 
was noted above. The carbon dioxide capacity of; the plasma fell slightly fol- 
lowing the discontinuance of soda on Mar. 22, also following discontinuance of 
wliisky on Mar. 24. In each case it readily rose again, and it is probable that 
neither alkali nor alcohol played an essential role. The ferric chloride reactions 
and the ammonia showed no such influence, On the carbohydrate test (Apr. 3 
to 15) the ferric chloride reaction became entirely negative. On beginning 
mixed diet, nothing was definitely altered in the CO2 capacity, and the ammonia 
was only slightly higher, but ferric chloride reactions began to recur as the caloric 
intake was raised, notwithstanding the fact that carbohydrate was similarly 
increased. Such reactions persisted up to May 22, with 50 gm. carbohydrate in 



324 



CHAPTER m 



the diet. Further increase to 65 gm. carbohydrate abolished them, and they 
remained -absent with further increase of carbohydrate, even though fat was 
also increased. 

Blood Sugar. — The curve shows the characteristics of an early case, still in 
the mild stage. It returned quickly to normal, rose only slightly as the diet was 
built up, then became and remained continuously normal, notwithstanding the 
high diet. 

Weight and Nutrition. — For nearly the first month in hospital there was under- 
nutrition. The practical abstinence from protein for 29 days is noteworthy, 
and there must have been a large loss of body nitrogen. The weight fell during 
the first part of the fast to Mar. 25, then began to rise on fasting with only 600 
cc. soup and 300 cc. coffee daily, and continued to rise on green vegetables, until 
on Apr. 3 it was 1.2 kg. higher than at admission and there was visible edema 
of face and ankles. The weight then diminished spontaneously, but water reten- 
tion evidently persisted, for the lowest point was gradually reached on May 10, 
when the diet was theoretically adequate. A slow continuous gain followed, 
and at discharge the weight was approximately the same as at admission. 

The diet prescribed at discharge represented over 2 gm. protein and 50 cal- 
ories per kg. of weight, diminished one-seventh by the weekly fast-days. Con- 
sideration was taken of the fact that the patient was a growing boy; also activity 
had been gradually increased, so that by July he was walking 7 miles daily in 
addition to other exercise. He was encouraged to develop his muscles, avoid 
mental strain, and plan a vocation in line with these purposes. In view of the 
normal results of all clinical and laboratory tests, the attempt was made to let 
him develop as nearly normally as possible, and the liberal diet was permitted to 
this end. 

Subsequent History. — The urine remained normal, and the patient kept up 
with his school work and exercised by bicycling and skating. On Oct. 9, the 
weight was 50 kg., it having been kept down by exercise as ordered. The physi- 
cal and subjective condition was excellent, but sugar was found to be 0.232 per 
cent in whole blood, 0.270 per cent in plasma. Increase of exercise was ad- 
vised instead of reduction of diet. Competitive sports had been strictly for- 
bidden for fear of excitement and strain. This was the only point in "which the 
patient was disobedient, for he resumed basket-baU and participated in inter- 
scholastic matches. More dental work was necessary, and three trips to the den- 
tist were followed by slight glycosuria each time. The carbohydrate was dimin- 
ished to 40 gm., and the dental operations thereafter produced no glycosuria, 
illustrating the usual dietary factor. The blood sugar continued to rise, being 
0.263 and 0.285 per cent in whole blood and 0.344 per cent in plasma on succes- 
sive examinations. Undoubtedly exercise, by consuming surplus calories and 
keeping down weight, delayed the progress of the diabetes far beyond the period 
at which active symptoms would have developed at rest; but it was not able en- 
tirely to take the place of caloric restriction. By request, the patient returned 
to the hospital during his school holidays, after Christmas, for observation. 



CASE RECORDS 325 

Second Admission. — ^The weight was now 53.8 kg.; i.e., a gain of 6.2 kg. since 
the first admission. There were barely perceptible sugar and ferric chloride 
reactions. After 2 days of fasting a carbohydrate tolerance test was begun 
on Dec. 29. Glycosuria resulted with only 175 gm. carbohydrate on Jan. 2, 1916, 
and persisted when this intake was continued for 3 days. It ceased following the 
green day of Jan. 5, when only 41 gm. carbohydrate were taken. Also the blood 
sugar, which on Dec. 30 was 0.35 per cent, fell to 0.164 per cent on the morning 
of Jan. 6. The patient was discharged on Jan. 9 and allowed to return to school, 
on a diet of 100 gm. protein, 5 gm. carbohydrate, and 2100 calories (approximately 
2 gm. protein and 40 calories per kg. on 52 kg. weight, diminished by the weekly 
fast-days). Clinically the condition was perfect, and laboratory findings were 
normal except for the hyperglycemia. 

Subsequent History. — The patient did not do so well this time, showed traces of 
sugar frequently and lost weight by reason of the consequent fasting. Instructions 
were sent for him to return to the hospital, but he was unwilling to give up his 
school work. Early in Feb. there was constipation and an attack of colicky 
abdominal pain without fever or nausea, but with glycosuria. The patient hoped 
to fast himself sugar-free without stopping school. He fasted 8 days, attending 
school during the first 6. Glycosuria increased instead of diminishing. On Feb. 
17 he was too weak to fast, and spent that and the following day lying down 
at home without nausea or vomiting, with increasing dyspnea and drowsiness. 
The only food eaten during the 8 days was four eggs and some bacon on Feb. 
18. This seemed to give a little strength. 

Third Admission. — The patient was readmitted at 3:15 p. m., Feb. 19, stupor- 
ous, but intelligent when roused, with deep noisy respirations, 25 per minute; 
typical odor; temperature 97.6°F., pulse. 114, small and thready; cheeks unnatur- 
ally flushed and pinched; tongue dry and red; urine showing intense sugar and 
ferric chloride reactions, containing enormous numbers of casts, and turning to a 
solid curd of albumin with the heat-acetic test. 

At admission, the CO2 capacity of the plasma was 26.4 vol. per cent. In the ab- 
sence of nausea, the bowels were moved by calomel in divided doses followed by 
30 cc. 50 per cent magnesium sulfate solution and a colon irrigation. Plain 
fasting was imposed, with 150 cc. clear soup, and the patient was urged to drink 
as much water as possible, the fluid intake on this fast-day thus amounting to 
1680 cc. By the next morning the cKnical appearance was practically unchanged, 
but the CO2 capacity of the plasma had fallen slightly, to 24.2 per cent. Because 
of this fact, and because the acidosis symptoms were said to have come on as a 
result of prolonged fasting, it was decided to feed as nearly a pure protein diet as 
possible, and to give moderate doses of sodium bicarbonate such as would prob- 
•ably not derange the stomach. The diet consisted of 600 cc. clear soup, 600 cc. 
coffee, 300 gm. thrice boiled vegetables, steak, and white of egg, with addition of 
10 gm. sodium chloride daily. The record is summarized in Table X. 



326 



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CASE RECORDS 327 

By Feb. 21, clinical improvement was perceptible and the albumin and casts 
had almost disappeared. Thereafter clinica;l betterment was rapid. The patient 
was kept in bed on account of weakness until Mar. 2, after which, notwithstanding 
the fasting, his strength permitted being up. The diet as shown represents first a 
high and subsequently diminished protein ration, with continuous undernutrition 
from the total energy standpoint. Glycosuria diminished but did not cease, and 
there was a still more marked subsidence of signs of acidosis. Beginning Mar. 1 
fasting was instituted, with 300 cc. clear soup, 300 cc. coffee, and 10 gm. sodium 
chloride daily. The glycosuria cleared up uneventfully, also the ferric chloride 
reaction became entirely negative even during the fast. The diet was subse- 
quently built up gradually in the usual way, and the patient was dischargted July 
29, 1916, weighing 39.6 kg., on a carbohydrate-free diet of 80 gm. protein and 
1550 calories, without fast-days unless demanded by glycosuria (approximately 2 
gm. protein and 39 Calories per kg.). Not only was the carbohydrate tolerance 
practically nil, but the patient was now a thin semi-invalid, cheerful and able 
to be about, but contrasting strongly with the fully healthy appearing lad that he 
was at the former discharge. Though the urine was free from sugar and ferric 
chloride reactions, and the ammonia excretion and plasma bicarbonate were within 
normal limits, hyperglycemia was persistent. A bad prognosis was given. 

Acidosis. — ^An example is afforded of the treatment of coma coming on during 
fasting, by means of protein feeding and moderate doses of alkali. Fat would 
presumably be harmful, both as furnishing acetone bodies directly and as de- 
tracting from the desired undernutrition. The value of carbohydrate is question- 
able with such high glycosuria, hyperglycemia, and D : N ratios. Protein presum- 
ably serves to protect body nitrogen, maintain strength, and supply material for 
ammonia formation, in addition to serving as a source of carbohydrate and to 
promote diuresis. In this instance such treatment was successful when pro- 
longed fasting, aided only with alkali, probably would have ended fatally. 

Subseqiient History. — The patient remained free from glycosuria at home 
except for occasional traces cleared up promptly by fast-days. At the beginning 
of Sept. he developed a cold and simultaneous glycosuria. He was accordingly 
readmitted to hospital Sept. 5, 1916. 

Fourth Admission. — The weight was 38.2 kg. The patient was not so strong as 
before, and had lost hope. No alarming symptoms were present, but a fast of 
8 days was required to clear up the heavy glycosuria and ketonuria. A carbohy- 
drate tolerance test with green vegetables alone showed a tolerance of 60 gm. 
carbohydrate under these conditions; but no carbohydrate was tolerated with 
mixed diet, and an intake of 60 gm. protein and 1200 calories was the maximum 
possible without glycosuria. The patient's appearance suggested tuberculosis, but 
the cold passed off readily with the clearing up of other symptoms by fasting, 
and there were no later symptoms or findings on examination suggesting tuber- 
culosis. The patient was discharged on Oct. 4, 1916, weighing only 35.2 kg., 
on a diet of 50 gm. protein and 1000 calories (1.4 gm. protein and 28 calories 
per kg.). From the laboratory standpoint the condition was as before; i.e., 
nearly normal urine with persistent hyperglycemia. 



328 CHAPTER in 

Subsequent History. — The patient passed through another cold late in Nov., 
for which he was treated by a private physician who did not attempt to abolish 
glycosuria and ketonuria. The cold passed ofiE, but when seen Dec. 13 the pa- 
tient was in very bad condition, with edema of face and legs, and too weak to 
rise from a chair without help. He was on a diet of 38 gm. protein, 10 gm. car- 
bohydrate, and 1000 calories, with continuous glycosuria and ketonuria. By 
Feb. 2 the strength had slightly improved, and edema was absent. He was on 
a diet of 40 gm. protein, 10 gm. carbohydrate, and 1200 calories, with sodium 
bicarbonate. Death occurred suddenly and without special symptoms. Mar. 
29, 1917. 

Remarks. — ^This was an early case of diabetes in the best type of patient, with 
hereditary taint excluded as thoroughly as possible, and with the utmost intelli- 
gence and fidelity in respect to everything pertaining to the treatment. The 
early course was rapidly downward, threatening coma within 3 weeks, and the 
case was then of the type generally described in text-books heretofore as un- 
controllable. These symptoms were promptly and easily cleared up, and a 
result was achieved which, according to former standards, was ideal. All cliiu- 
cal and urinary symptoms were abolished and a high carbohydrate tolerance was 
restored. Weight and strength were built up, and the blood sugar also was nor- 
mal. The attempt was niade to let the patient return to normal activities on a 
liberal caloric ration. The activity may have been permissible. The diet was 
calamitous. It is not to be supposed that the carbohydrate allowance was too 
high. There is not necessarily any harm in the fact that the protein at the 
first discharge was up to the Voit standard (1.7 gm. per kg.; one-sixth of total 
calories). But the average energy intake was 43 calories per kg. Vigorous 
exercise and moderate restriction of weight did not atone for this overload im- 
posed upon a weakened metaboUsm. Efl&ciency and health are known to be pos- 
sible on a far lower intake. With some reduction of weight, Ufe could have been 
well maintained on half to two-thirds this number of total calories. As usual, 
the time actually arrived later when the boy was compelled to live on less than half 
this number of calories. The fatal mistake lay in imposing this strain upon his 
weakened function at the outset, so that it later broke down and was incap- 
able of carrying adequately half this burden. The proper treatment would clearly 
have consisted in limiting the burden in the first place, so as to avoid such a break- 
down. The case is a perfect example of what was formerly called "spontaneous 
downward progress" in diabetes. 

By comparison with other cases taken under far worse conditions and treated 
on a different principle, it can be concluded that the downward progress in this 
case was due chiefly or solely to the treatment employed. Even in the later stages 
the diets permitted were such as taxed the weakened tolerance to the utmost. 
But the essential harm was done at the most favorable period, and the fatal out- 
come was assured by the methods employed at the very time when the prognosis 
seemed brightest. 



CASE RECORDS 329 

CASE NO. 38. 

Female, married, age 39 yrs. Russian Jew; housewife. Admitted Mar. 20, 
1915. 

Family History.— FaXhex died at 65. Mother, one brother and sister are well; 
one brother died of phthisis. No other diseases known. 

Past History.— No illnesses known. Said to have been treated at a hospital 
2 years ago for "large liver and abdomen," cured by wearing a support. Habits, 
appetite, and bowel action normal. No excesses. Last menstruation was S 
months and 3 weeks before admission. 

Present Illness. — Began with chilly sensations and malaise 1 week ago, 
followed by cough, fever, and pain, particularly in left lower chest. 

Physical Examination.— A well developed and nourished woman, 5 or 6 months 
pregnant; flushed cheeks, slightly bluish lips; lymg in bed breathing about 40 
times per minute and groaning frequently. Tongue coated and dry; teeth false; 
tonsils and lymph nodes not enlarged. Pulse 110, temperature 102.8°. Blood 
pressure 150 systolic, 90 diastolic. Signs of pneumonia of left lower lobe. Liver 
edge 3 cm. below costal margin. Knee jerks not obtainable. Examination 
otherwise negative. Sputum was mucopurulent, yellowish gray, containing 
Gram-positive diplococci, not agglutinated by Pneumonia Serum I or II. Blood 
culture was sterile. Leucocytes 22,000, polymorphonuclears 91 per cent, lympho- 
cytes 5 per cent, large mononuclears 4 per cent. Urine contained some albumin 
and casts and showed heavy sugar and ferric chloride reactions. 

Treatment. — The patient was received on the pneumonia service, and the finding 
of diabetes was unexpected. The temperature feU to normal within 24 hours, 
but the pulse and respiration continued elevated. 

After death a needle inserted in the third intercostal space close to the ster- 
num, with the idea of obtaining blood from the heart, yielded an abundance of 
very turbid gray fluid, which clotted quickly on standing, showed leucocytes 
but no bacteria in films, and was sterUe on culture — apparently a large peri- 
cardial effusion. Necropsy was not permitted. 

Remarks. — ^This is another example of diabetes discovered during the course 
of an acute infection. Whether the infection produced it, or (more probably) 
made active a latent or mild diabetes, is undetermined. The severity of the 
acidosis is indicated by the low blood bicarbonate with large doses of alkali. 
In expectation of the use of such doses, cathartics were omitted, and, as antici- 
pated, moderate persistent diarrhea was kept up by the bicarbonate, the dis- 
crepancy between fluid intake and output being thus accounted for. The impres- 
sion was created that the alkali in such doses was definitely beneficial, and that 
smaller doses would not have sufficed. Notwithstanding the combination of in- 
fection and existing coma on Mar. 26, the acidosis symptoms passed off, and the 
blood bicarbonate on the day of death was nearly normal. It is possible that 
death was partly due to the diabetic intoxication, which may exist in the absence 
of some of the signs of acidosis, but there is entirely sufficient cause for death 



330 



CHAPTER III 



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332 CHAPTER III 

without this assumption. It was not the intoxication sometimes attending upon 
fasting, because the typical nausea was absent, and the food retained on Mar. 29 
.brought no improvement. In summary, it may be said that pneumonia, middle 
ear infection, death of fetus with subsequent artificial delivery, and either peri- 
carditis or empyema, constituted a sufficient explanation of the fatal result, 
and under these conditions 5 days of very low diet followed by 5 days of fasting 
failed to control the diabetes. 

CASE NO. 39. 

Female, unmarried, age 27 yrs. American; teacher. Admitted Apr. 3, 
1915. 

Family History. — ^A maternal grandfather died of cancer with suspicion of 
accompanying diabetes. A paternal aunt was insane 15 years ago, but has ap- 
parently recovered. Patient's mother died of diabetes at 37. Father is well, 
aged 70, but had nervous breakdown 25 years ago which kept him from work 
for 3 years. Strong neurotic element in family. A brother of patient is a young 
physician, of nervous temperament. A sister died of heart trouble within a 
few months after birth. No syphilis, tuberculosis, or other diseases known. 

Past History. — General healthy life under good hygienic conditions in small 
New England towns. Several childhood diseases, including scarlet fever, said to 
have been followed by ear trouble and nephritis. No other illnesses. Habits 
regular; always nervous in disposition. 

Present Illness. — ^About 4^ years ago headaches began and transitory poly- 
dipsia and polyuria. The patient was first dieted by a local physician, then be- 
ginning in the spring of 1913 she was under Dr. Jbslin's care several times. He 
found her a model patient in hospital and the glycosuria was easy to stop, but 
the patient appeared mentally incompetent whenever she returned home and 
never had the will power to adhere to diet. On certain occasions she 
wandered from home in lapses of consciousness, and she was regarded by Dr. 
Joslin as definitely insane, though bright and active most of the time. In 
the summer of 1914, after heavy mental and physical strain, she suddenly lost 
consciousness for 1 day and was stuporous for 6 days thereafter. Her local 
physician called the condition diabetic coma. She recovered on fasting and 
bicarbonate. Thereafter she made some attempts to follow diet, but home con- 
ditions were difficult and glycosuria and ketonuria were continuous. 

She was admitted to a New York hospital in Mar., 1915, with facial neuralgia 
of intense type. Here again glycosuria cleared up rather easily, but there was 
the same difficulty regarding adherence to diet, and here also the patient was 
considered mentally irresponsible to the point of insanity. The neuralgia, how- 
ever, ceased with the improvement in the urinary symptoms. The patient was 
financially unable to remain longer under hospital expense, and was admitted 
to this Institute on Apr. 3, 1915, for the purpose of testing the effects of pro- 
longed thorough treatment, not only upon the diabetes but also upon the nervous 
and mental condition. 



CASE RECORDS 333 

Physical Examination.— Yiti^t 168.1 cm. A well developed and nourished, 
nervous appearing young woman. Hair thin, short, and dry. Eyes slightly 
prominent. Suspicion of slightly enlarged thyroid on palpation. Knee and 
ankle jerks normal. Examination otherwise negative. 

Treatment. — Glycosuria and ketonuria were present. After a single fast-day 
on Apr. 4, notwithstanding faint traces of glycosuria, small quantities of green 
vegetables were begun. Glycosuria stopped even while they were increased, and 
remained absent until, on Apr. 15, the vegetable diet (including com and peas) 
represented 42 gm. protein and 150 gm. carbohydrate. Although the fat in such 
diets was only 40 gm., marked ferric chloride reactions steadily persisted with 
this carbohydrate intake, and with 170 gm. carbohydrate on Apr. 16. Apr. 17 
was a fast-day followed by diets of 800 and 450 calories on Apr. 18 and 19, and then 
6 days of complete fasting, 150 cc. clear soup being permitted, except on Apr. 
23 and 24, when nothing but water was given. The persistent glycosuria and 
elevated blood sugar strongly suggest surreptitious eating during this time. 
The usual diet was begun on Apr. 26 and rapidly increased, until for a short time 
after May 24, 90 to 100 gm. protein, 40 gm. carbohydrate, and 2300 calories 
were tolerated. On account of persistent slight glycosuria (June 3 to 7) fasting 
was imposed. No other interpretation seems possible than that this was due to 
forbidden food obtained in some manner not discovered; but the policy of fast- 
ing until glycosuria ceased was a salutary check to such practices. Thereafter a 
slightly lower diet was tolerated with occasional traces of glycosuria, some of 
which were confessedly, and others probably, due to candy or other prohibited 
foods. After fast-days on July 24 and 25, a carbohydrate test was instituted, and 
showed a tolerance of approximately 300 gm. carbohydrate ip the form of green 
vegetables. The hospital discipline had benefited the patient, and this indica- 
tion of improvement was a great encouragement to her. 

She was discharged Aug. 13 on a diet of 100 gm. protein, 30 gm. carbohydrate, 
and 1900 calories (about 1.8 gm. protein and 34 calories per kg.), the weekly 
fast-days reducing the average to about 1.4 gm. protein and 30 calories per kg. 
She promised faithfully to adhere to this diet. There was unmistakable psychic 
as well as physical change in the patient, and though still nervous she was clearly 
more dependable and better fitted to take care of herself. 

Acidosis. — At entrance the ammonia nitrogen was only 0.56 gm. and the 
ferric chloride reaction mostly no more than moderate; but the plasma bicarbonate 
showed the rather low level of 47 per cent on Apr. 5 and 45 per cent on Apr. 7. It 
thus fell slightly during the days of very low carbohydrate, which were almost equiv- 
alent to fast-days (10 gm. carbohydrate and 300 cc. soup daily). With continu- 
ance of undernutrition and slight increase of carbohydrate, it rose sharply within 
normal limits by Apr. 9, without the use of alkali. Thereafter the curve ran a 
normal course but seemed to tend to fall with fasting, being found slightly below 
normal on May 3, following the preceding fast-day, and again after fasting on 
July 26. The consistent course of the ammonia curve was low. A slight ferric 



334 CHAPTER in 

chloride reaction tended to persist. It gradually faded out and became negative 
in periods, and after the carbohydrate test in July and Aug. it became consistently 
negative. 

Blood Sugar.— On Apr. 7, just as the glycosuria was clearing, the blood sugar 
was just below 0.2 per cent, indicating a normal renal threshold. With further 
days of low carbohydrate, it had fallen to normal on Apr. 9. The carbohydrate 
tolerance test led to hyperglycemia of 0.22 per cent with glycosuria on Apr. 16. 
The excessively high figure shown on Apr. 22 was not checked and therefore 
might have been a mistake. Thereafter the values tended to fall below 0.15 
per cent. Other work made it necessary to stop the analyses; on this case after 
May 18. > 

, Weight and. Nutrition. — The patient entered in a very well nourished condition 
weighing 59.2 kg. She was still well nourished at discharge, weighing 55.8 kg. 
The net result of treatment was thus undernutrition to the extent of a loss of 3.4 
kg. With the clearing of diabetic symptoms there W9,s the usual gain in strength 
and well-being, and the patient felt entirely well at discharge. 

Subsequent History.— The: patient resumed her regular work at home and fol- 
lowed diet surprisingly well. On three occasions she went' on what she termed 
"sprees" of carbohydrate, but experienced symptoms of weakness and.mp,laise 
within a limited number of hours after the onset of the heavy glycosuria, and 
cleared up her condition, generally after some delay, by fasting, on one or two 
occasions as long as 5 days. Against external as well as internal difficulties she 
kept up a continuous effort to remain sugar-free, and notwithstanding the lapses 
from diet, continued to gain in weight and subjective health. On account pf 
sugar and ferric chloride reactions in urine specimens received, it became advis- 
able to readmit the patient on Jan. 12, 1916, 5 months after discharge. 

Second Admission. — The weight had now risen to 64.1 kg.; i.e., 4.9 kg. more 
than at the former admission, and both the physical and mental condition ap- 
peared excellent. On the diet prescribed at discharge, the plasma sugar was 
0.264 per cent and the CO2 capacity 49 per cent. There was a heavy ferric 
chloride reaction, and 2.18 gm. ammonia nitrogen in the > urine. Fast-days on 
Jan. 19 to 20 sufficed to clear up the glycosuria, but the tolerance on the ensuing 
days with green vegetables proved to be now only 50 gm. carbohydrate. Though 
diets lower in both carbohydrate and total calories were employed, it was diffi- 
cult to obtain freedom from traces of glycosuria. During late Mar. and early . 
Apr. there was decided intolerance for a diet of 65 gm. protein, 15 gm. carbohy- 
drate, and 1500, calories. After Apr. 16, carlaohydrate was excluded. Even on 
diets as low as 60 gm. protein and 1000 calories, traces of glycosuria recurred. 
But with continuance of this undernutrition they remained absent after May 
2, and by May 12, 70 gm. protein and 1400 calories were tolerated. With redu,Cj- 
tion of one-seventh by weekly fast-days, this represented approximately 1 gm. 
protein and 20 calories per kg. of weight. The patient was discharged on this 
diet May 13, 1916. , , 



CASE RECORDS 335 

Acidosis. — The CO2 capacity of the plasma rose easily within normal limits 
without the aid of alkali, and remained so except for a single low reading on 
May 9. The ammonia excretion at the outset was much higher than before, 
i. e. 2.18 gm. N; also the ferric chloride reaction was heavier. Thus these signs 
indicated a higher acidosis than at the former admission, though the plasma 
bicarbonate was 2 per cent higher than then. Isolated determinations on Feb. 
7 and 21 indicated about the same subsequent level of ammonia as at the pre- 
vious period in hospital. The ferric chloride reaction cleared up much more 
easily and promptly than before, although the diets were so much poorer in 
carbohydrate than before and frequently carbohydrate-free. This result is ex- 
plained by two causes, first, the previous treatment, and, second, the lower total 
caloric i value of the diets at this admission. The ferric chloride reaction was 
thus negative on carbohydrate-free diet at discharge. 

Blood Sugar. — An aggravation of the condition was indicated by the fact that 
even on low diets the blood sugar never became normal, but remained above, 
rather than below 0.15 per cent. More rigorous treatment could presumably 
have reduced the hyperglycemia even at this stage. 

Weight and Nutrition. — The patient's gain in weight during her absence from 
hospital would once have been regarded as an improvement. Its real meaning 
is that the diabetes was sufficiently mild to permit a gain in weight even in the 
presence of glycosuria, and in this mUd stage injury was wrought by exceeding 
the true functional power with respect to both diet and weight. After readmis- 
sion to hospital, the weight at first fell from undernutrition, then fluctuated, 
and on two occasions, namely Mar. 7 and 8, and Apr. 28, rose higher than at ad- 
mission, because of marked edema. This edema was not associated with any alkali 
administration, but may have been due to sodium chloride. The weight at dis- 
charge was 61.2 kg., being 2 kg. higher than at the first admission and 2.9 kg. 
lower than at the second admission. A portion of this weight may stUl have 
been abnormally retained water, which however was not apparent on examina- 
tion. The diets in general represented undernutrition, and the diet at discharge 
meant further undernutrition and reduction of weight. 

Subsequent , History. — The patient undertook to support herself by visiting 
and other duties in connection with diabetic patients of a physician in New 
York, and one stay at a country place was also arranged. She remained free 
from glycosuria through the summer, but her diet became uncertain by reason of 
her preparing her own meals under irregular conditions and making trials of 
various modifications to suit herself. She finally undertook too heavy a load of 
work and took too high diets in the attempt to keep up with her ambitions. 
She managed to remain in fair condition as respects, diabetes, and in good con- 
dition as respects general health, until readmitted Dec. 30, 1916. 
■ Third Admission.— The weight was still 62.7 kg., partly due to edema. The 
general appearance, strength, and behavior showed no perceptible change. 
Downward progress was indicated by the fact that a 7 day fast was neces- 



336 CHAPTER in 

sary this time to bring the glycosuria under control. The subsequent history in 
hospital was uneventful. The patient broke diet on a few occasions, otherwise 
she was maintained sugar-free, and was dismissed Apr. 10, 1917, weighting 57.2 
kg. on a diet of 60 gm. protein, 2.5 gm. carbohydrate, and 1300 calories. The 
patient's intentions in regard to work were now the principal difSculty. She 
was determined to carry a heavy load of work, and was not willing to undergo 
undernutrition to a point which would diminish her working capacity. As 
inevitable in such cases, the long abuse of the weakened assimilative power had 
now brought the point where maintenance of full weight and working power was 
impossible. The tolerance could be benefited only by undernutrition diets such 
as prescribed. Such reduction must continue for several months before any gain 
could be expected, and the damage already wrought -was such that a full return 
to the former tolerance was undoubtedly impossible. The patient, though intelli- 
gent and grateful, was unwilling to accept life on these terms, and proposed from 
her knowledge of diets to nourish herself with a view to temporary working 
capacity as long as possible. 

Subsequent History. — The patient took mixed diet with restriction of all three 
classes of food, but the period of ability to work was very brief. All her former 
symptoms quickly returned except the neuralgia. The mental abnormality 
again showed itself markedly. Though appearing bright and merely nervous in 
public, in private she tore her clothing, bit and otherwise injured herself, and 
made several attempts at suicide. She recognized symptoms of acidosis, 
and accordingly excluded fat almost completely from her diet. It was learned 
indirectly that she was in serious condition, and she was accordingly sent for 
and brought back to the hospital by a nurse on June 18, 1917. 

Fourth Admission. — There was a history of edema a week before. The pa- 
tient took two capsules of 8 grains diuretin, and edema is said to have disap- 
peared rapidly, and epigastric pain began. Smce then weakness and dyspnea 
have rapidly increased, so that she has remained lying down for the past 2 days. 
On the day before admission there was nausea and vomiting, and she took two 
teaspoonfuls of sodium bicarbonate; otherwise she has had no alkali. Also dur- 
ing these 2 days she claims to have fasted, partly from lack of appetite and 
partly in the attempt to treat herself for acidosis. Weight was 58.1 kg.; i.e., 
1.1 kg. less than at first admission. The patient lay in bed, evidently extremely 
weak. The general appearance was about as before. Neither emaciation nor 
edema was present, also the tissues were not perceptibly dry or flabby. There 
was a deep dusky flush of cheeks, involving lower eyelids. Air-hunger was in- 
tense; deep pauseless respirations 22 to 23 per minute as the patient lay 
in bed; so extreme on the slightest exertion that drinking and speaking were 
difficult. The patient dozed continually when undisturbed, but roused easily and 
rather nervously. Intelligence was fully clear, and she was entirely cheerful, 
while convinced that death was imminent. Physical examination was negative 
except for a row of herpes vesicles beginning to dry up under the left breast. 



CASE RECORDS 337 

These and associated tenderness explained the epigastric pain still complained 
of, as due to intercostal neuralgia. 

Inasmuch as symptoms of serious acidosis had begun and persisted while fat 
was diminished or even excluded from the diet, and signs of coma had appeared 
after 2 days of supposedly complete fasting, it was difficult to decide upon a line 
of treatment for the threatening crisis. It was feared that the existing nausea 
would be increased by alkali. An attempt was therefore made first with plain 
fasting with soup and coffee and water forced to the limit of capacity. The 
plasma bicarbonate was 30.5 per cent, the heart and kidneys were keeping up well, 
and there was no sign of immediate death. It therefore seemed most conserva- 
tive to wait a few hours to learn the behavior under fasting alone. The actual 
progress was rapidly downward, perhaps partly on account of exhaustion from 
the trip to the hospital. Unmistakable progress into coma was evident. The 
patient was received at 4:30 p.m. By evening moderate doses of alkali by 
mouth were begun; by midnight there had been given 10 gm. sodium bicarbonate, 
30 cc. whisky, and 2105 cc. total fluids. By 9 a.m. June 19, an additional 15 gm. 
sodium bicarbonate and 30 cc. whisky had been taken, yet the plasma CO2 had 
fallen to 20.7 per cent, and the sugar and total acetone of the plasma were de- 
cidedly increased. During June 19, 1 gm. doses of sodium bicarbonate were 
given hourly with 5 gm. doses of calcium carbonate, in the hope that the latter 
would help settle the stomach and possibly have some acid-neutralizing power. 
Whisky was given in 15 cc. doses every 4 hours, 1800 cc. soup during the day, 
and 15 gm. sodium bicarbonate. The total fluid intake was 9805 cc. By 10:30 
p.m. improvement seemed to have been obtained. The breathing seemed 
quieter, the consciousness clearer, and the CO2 capacity had risen to 27.7 per 
cent. By the next morning the patient had begun to refuse bicarbonate because 
of nausea, and the coma sjonptoms showed increase. An attempt was therefore 
made to supply fluid and a moderate quantity of alkali intravenously. Accord- 
ingly, 500 cc. physiological saline solution, containing 13 gm. sodium bicarbonate 
were given slowly through a needle. The breathing became quieter, but an 
attack of vomiting resulted and consciousness did not improve. It was then 
attempted to feed protein in the form of white of egg mixed in the soup. The 
small quantities thus given were retained several hours, then vomited. Com- 
plete unconsciousness came on, with continuance of the intense dyspnea, and 
nothing seemed left but to attempt to raise the blood alkalinity by larger doses of 
soda intravenously, notwithstanding the known danger. Accordingly 1 hter of 
saline solution containing 38 gm. sodium bicarbonate was given in an injection 
into the arm vein in half an hour. Dyspnea diminished. The pulse, which was 
strong, was unchanged. The flush of the cheeks became paler. Consciousness 
was not restored, and an attack of vomiting was excited. Unconsciousness with 
slight restlessness continued until 5 p.m., when there occurred the sudden death 
without warning which is rather characteristic following large intravenous doses 
of alkali. The principal data are contained in Table XII. 



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338 



CASE RECORDS 339 

Remarks.— This was one of the cases with exaggerated protein catabolism, as 
indicated by the nitrogen excretion of 23.7 gm. on June 19. On June 20, an equal 
or higher quantity must have been eliminated, but large quantities of urine passed 
involuntarily were lost, and also death occurred at the end of 17 hours of this 
day. Any error of diet as an explanation of the high D : N ratios is excluded, 
as the patient was stuporous and isolated in a room with a special nurse. Only 2 
days of fasting, according to the patient's report, had intervened since her period 
of liberal diet, including carbohydrate. The nutrition was well maintained as 
stated, and it must be assumed that with the rapid and intense change for the 
worse, body glycogen was being swept out. 

Several lines of treatment are open in such a case, but death occurs in a great 
majority under these circumstances no matter what is done. Treatment without 
alkali and -vjithout food, but supplying fluid and salt, was first tried with ominous 
results. Another possibility would have been fasting with alkali from the outset. 
Dosage by mouth could have accomplished nothing more by reason of nausea. 
There might have been some real helpfulness in small intravenous doses of bicar- 
bonate at intervals of a few hours, perhaps alternating with doses by mouth. 
It appeared, however, that considerable quantities of alkali were necessary to 
affect the blood alkalinity, and this excited nausea even when given intravenously. 
Another possibility lay in feeding with or without alkali. It is highly question- 
able if carbohydrate is of any benefit in the presence of a maximal D : N ratio. 
Fat would seem to promise nothing but harm. Protein might have been bene- 
ficial; but again it may be that an attempt to feed anything wiU sometimes aggra- 
vate a condition of impending coma. A noteworthy feature is the fact that the 
renal function was weU maintained to the end, and large quantities of urine were 
passed involuntarily in the closing hours of life. It is now less common for pa- 
tients received with impending coma to go into coma under treatment, but with 
the exaggerated protein catabolism and continued maximal D : N ratios, such a 
result is still often unavoidable. 

In its general aspects the case illustrates the interrelation of diabetes and 
nervous disorder, and the actual symptomatic improvement of the latter under 
careful treatment of the former. Had either the psychic state or the environ- 
ment been more favorable, something might have been accomplished; but with 
both adverse, the patient made a brave effort but lost in the end. 

CASE NO. 40. 

Male, unmarried, age 29 yrs. American; doorman. Admitted Apr. 12, 
1915. 

Family History. — Little known; no history of disease obtainable. 

Past History. — Measles, whooping-cough, scarlet fever in childhood. Right- 
sided pneumonia 15 years ago. Neisser infection, also chancre some years ago; 
no secondary symptoins and no treatment. Frequent colds, but rarely sore 



340 CHAPTER III 

throat. Formerly used whisky to excess, but recent alcoholism denied. He 
smokes pipe and cigars in moderation, and takes two cups of coffee and three 
of tea a day. He sleeps well, has poor appetite, and regular bowels. No known 
loss of weight or other diabetic sjrmptoms. 

Present Illness. — Patient entered on the pneumonia service 24 hours after 
initial chill. He had a severe Type I pneumonia involving lower lobes on both 
sides, with positive blood culture. Leucocytes 24,800, polymorphonuclear 90 
per cent. Highest temperature 104°. Blood pressure 125 systolic, 70 diastolic. 
Physical examination otherwise negative. 

Treatment. — Urine was smoky red and showed heavy albumin, slight Benedict, 
and moderate ferric chloride reaction. He was treated on the pneumonia serv- 
ice with Type I pneumococcus serum. The blood became promptly sterile; 
the temperature, pulse, and respiration remained elevated. On Apr. 12, the diet 
consisted of 370 cc. milk, 150 cc. broth, and 150 cc. albumin water. On Apr. 13, 
300 cc. albumin water, ISO cc. soup, and ISO cc. cocoa were given, and there 
was shght glycosuria and a slight ferric chloride reaction. On Apr. 14, 700 cc. 
albumin water and ISO cc. soup were the diet, and both sugar and ferric chloride 
reactions diminished to traces. Apr. 15 and 16, the diet was similar but included 
also 200 to 400 cc. mUk. Traces of sugar and diacetic acid persisted. Meanwhile 
the temperature ranged from 101. 2-103. 6°F. Beginning Apr. 17, the patient 
was placed partly under the care of the diabetic service because of abnormal 
drowsiness and hyperpnea. On that day 15 gm. sodium bicarbonate were given, 
and the diet was changed to clear soup and whisky. On Apr. 18, 40 gm. sodium 
bicarbonate were given, and the previously acid urine turned neutral for part 
of the day. On Apr. 19 another 40 gm. sodium bicarbonate were given, and the 
urine was neutral throughout the day. On Apr. 20, the urine again turned acid, 
but another 40 gm. bicarbonate then turned it alkaline. Continuance of 40 gm. 
sodium bicarbonate on Apr. 21 and 30 gm. on Apr. 22 kept the urine neutral 
or alkaline. Meantime the ferric chloride reaction, from almost negative, had 
became intense. Under the influence of the alkali dosage the drowsiness cleared 
up. Apr. 23, 50 gm. carbohydrate in the form of. green peas were tolerated, but 
100 gm. in the form of peas and potatoes on Apr. 24 caused slight glycosuria. 
Beginning Apr. 25 a diet of soup, eggs, and vegetables was given, mostly about 
1000 calories. Because of the stubborn ferric chloride reaction, fastmg was im- 
posed on May 2 and 3, and then a diet of vegetables up to May 6, containing a 
maximum of 75 gm. carbohdyrate. On May 7, a low carbohydrate-free diet of 
less than 500 calories was given for the purpose of avoiding too long continued 
abstinence from soUd food in a patient with infection. A mixed diet was then 
gradually built up, glycosuria appearing on May 16 with an intake of 67 gm. pro- 
tein, 75 gm. carbohydrate, and 1700 calories. The diet nevertheless was still 
built up, and the tolerance rapidly improved with subsidence of the infection. 
The signs in the lungs persisted unduly long. Sermn sickness with urticarial 
eruption was present Apr. 20 to 26. On May 10, the left seventh rib was resected 



CASE RECORDS 341 

under local anesthesia for drainage of the empyema. It will be noted that gly- 
cosuria and a trace of ferric chloride reaction appeared on May 11, seemingly in 
consequence of this operation, and promptly cleared up without reduction in 
diet. The temperature subsided somewhat, but persisted in the neighborhood 
of 100°. Albuminuria had gradually diminished and was negative after May 10, 
but edema of the ankles persisted. On June 12, there appeared a fusiform swell- 
ing of three fingers of the right hand, and later also in joints elsewhere. The tem- 
perature rose at this time, but there was no glycosuria, and the ketonuria was 
only such as could be explained by the high fat of the diet. Thereafter the 
temperature gradually diminished and was normal after July 1. From the 
diabetic standpoint, the diet was built up to a high level, not only for the pur- 
pose of strengthening the patient, but also for the purpose of testing his toler- 
ance. The latter proved to be almost unlimited. Carbohydrate was increased 
through the various classes of food, until the tolerance was found above 200 
gm. in diets containing fruits, potatoes, cereals, and bread. _ Cane sugar was 
then permitted, beginning with 50 gm. on July 19, and glycosuria remained 
absent until a brief trace appeared on July 23 on an intake of 119 gm. protein, 
380 gm. carbohydrate, and over 3900 calories. On July 22, he had tolerated such 
a diet, including 200 gm. cane sugar distributed throughout the day. On July 
23, the carbohydrate allowance included this same quantity of sugar, but it was 
given all at once, and a trace of glycosuria was present for a few hours. The 
patient was therefore sent out on fuU mixed diet, on the presumption that the 
diabetes had been transitory. 

Acidosis. — ^The case is an illustration of threatened coma under the influence 
of infection in a patient never known to have been diabetic, kept on very low 
diet because of the inability to take more, and with only slight sugar and ferric 
chloride reactions in the urine. The actual acidosis was revealed by the quanti- 
ties of alkali required to turn the reaction of the urine, and by the intense ferric 
chloride reactions which resulted. Relatively few analyses had been made at the 
outset while the infectious features predominated. On Apr. 21, the first am- 
monia determination showed the low value of 0.59 gm. N under the influence of 
alkali. With omission of alkali, the ferric chloride reaction cleared up quickly 
but temporarily, and the ammonia nitrogen on Apr. 24 shot up suddenly to nearly 
2.5 gm. By Apr. 26, adjustment had occurred under the influence of continued 
undernutrition and a little carbohydrate, and ammonia values thereafter never 
reached an alarming level. More or less ferric chloride reactions recurred until 
June 16, especially by reason of the high fat intake, but thereafter 75 gm. or more 
of carbohydrate in the diet sufficed to abolish ketonuria even with abundance 
of fat. 

Weight and Nutrition. — The 1st month in hospital represented marked under- 
nutrition, particularly in view of the fever. The body weight was kept up by 
edema. Beginning May 7, there was a sharp decline in weight with subsidence 
of edema, and after June 4 the weight rose rather rapidly under the liberal diets. 



342 CHAPTER III 

Remarks. — The case is an example of diabetes occurring with an acute infection 
under circumstances which make it appear that the infection had given rise to 
the diabetes. It is open to speculation whether the diabetes would have 
passed off if heavy glycosuria had been maintained by excessive carbohy- 
drate feeding from the outset, especially as this might actually have been em- 
ployed under former methods of treatment for the purpose of controlling acidosis. 
It was also important to determine whether the diabetes was actually transitory, 
presumably the result of direct or indirect involvement of the pancreas, or whether 
the infection merely brought into prominence a latent diabetes. The normal 
sugar tolerance at discharge would point to a genuinely transitory diabetes. 
On the other hand, the only decisive test would lie in following such a patient for 
many years. If diabetes ultimately became manifest, it might then mean either 
a latent diabetes, antedating an infection and temporarily made active by it, or it 
might represent injury of a previously normal pancreas by the infection, with tem- 
porary recovery to a considerable degree, with impairment and later breakdown of 
the internal function. None of these questions could be answered because the 
patient was lost sight of in spite of attempts to foUow him up. • 

Among the features of the treatment, the most striking seems to be a defi- 
nitely beneficial effect of alkali which cleared up symptoms threatening coma, 
when fasting and low diet were accompanied by dangerous acidosis and when the 
patient was in no condition to take much food. It is also worth noting that 
coma may threaten under such conditions with only sUght sugar and ferric 
chloride reactions and with diabetes apparently of mild degree. 

CASE NO. 41. 

Male, married, age 52 yrs. Irish; poKtician. Admitted Apr. 23, 1915. 

Family History. — Parents died in old age. One brother well; two died in in- 
fancy. One sister well; one died in infancy; one died of tuberculosis at 33. There 
was mental disorder running through several generations on the mother's side. 
Two of the patient's aunts died in insane asylums. No diabetes or other diseases 
in family. 

Past History.— Healthy and checkered life. Measles, mumps, chicken-pox, 
scarlet fever, diphtheria in childhood; no sequelae. Bom in Ireland, ran awaly 
to sea at age of 20, and worked mostly as a stoker in the tropics for 7 years, but 
continued to enjoy good health. He then came to New York, worked at manual 
labor for a number of years, then gained influence in labor organizations and poU- 
tics, and has since been occupied in ofiicial positions. There was cough and 
loss of weight shortly after his arrival in New York; tuberculosis was diagnosed, . 
but there was apparently complete recovery. He also had pleurisy and "shingles" 
20 years ago, but recovered rapidly, and has never been iU since. Venereal his- 
tory consists in Neisser infection in 1883, followed by inguinal buboes treated by 
incision in hospital. Chancre in 1885, followed by slight rash 3 weeks later. 



CASE RECOIIDS 343 

Habits have generally been good in view of hard life. Not mbre than 2 or 3 
drinks a day, generally beer. Has never used tobacco. The diet on shipboard 
left him with more or less indigestion. Bowels usually regular. He has eaten 
rather liberally of sweet foods. 

Present Illness. — 4 years ago he was troubled with dry throat following a 
cold. Physician in routine examination found 2 per cent glycosuria. Shortly 
after this polyphagia, polydipsia, and polyuria set in, but disappeared on mod- 
erate restrictions of diet. There has been no attempt to make him sugar-free. 
6 months age he barked his shins; these were very slow in healing, and collections 
of pus required opening. Since Mar. 17, he has had a grippe infection and con- 
siderable impairment of general health, and his physician advised him to come 
to the Institute for diabetic treatment. The loss of weight has amounted to 15 
pounds in the past 3 years. 

Physical Examination. — Height 172 cm. Awell developed, strong looking, some- 
what obese man, showing no distress, but with cyanosis of face. Temperature 1 02° 
F., pulse 120, respiration in bed 36. Breathing not of air-hunger type. Teeth all 
false. Throat slightly congested; tonsUs show slight hypertrophy without exu- 
date. Lungs, slight bronchitis and emphysema. Slight generalized enlargement 
of lymph nodes. Blood pressure 125 systolic, 70 diastolic. Reflexes normal. 
Pigmented scars on shins; sHght edema of ankles. Wassermann -j--|- in blood, 
negative in spinal fluid. Physical examination otherwise negative. 

Treatment. ^-On admission there was a rnoderate sugar and slight ferric chloride 
reaction, and a heavy trace of albuminuria with large mmibers of hyaline and 
finely granular casts. On Apr. 24, the first full day in hospital, the diet was 84 
gm. protein, 3 gm. carbohydrate, and 2375 calories. Glycosuria entirely cleared 
up during the day, and the ferric chloride reaction was also negative. Fasting 
was begun, nevertheless, as the quickest means of undernutrition, and was con- 
tinued for 8 days. The temperature and cough cleared up during this time, also 
the albuminuria gradually diminished to a trace. The patient was fully com- 
fortable, and on 450 cc. soup daily had no special complaint of himger. Green 
vegetables were the first food given, in the form of a tolerance test. The gly- 
cosuria with 20 gm. carbohydrate on May 4 was an accidental trace, not repre- 
senting the true limit, which was reached with 100 gm. carbohydrate on May 
8 and 9. This glycosuria ceased on cutting down the carbohydrate to 21 gm. 
on May 10. Beginning May 11, two eggs and 50 gm. bacon were given as the 
first substantial food in the 18 days since admission. 10 to 20 gm. carbohydrate 
were retained in the diet, which was gradually built up to 65 gm. protein and 1330 
calories on May 16 and 17. That this diet was too high was indicated by the 
sharp rise in ammonia, and the high blood sugar on the morning of May 18. 
The fact that glycosuria was absent then, but traces were present on certain 
subsequent days, is possibly a phenomenon of renal permeability. Albumin 
and casts were absent from the urine after May 9, and renal function tests by 
Dr. McLean showed no abnormality throughout. It became possible to increase 



344 CHAPTER III 

all three classes of food rather rapidly. There was more feelipg of hunger toward 
the close of May than on the fasting and lower diets previously. On May 13, 
0.2 gm. salvarsan, and 0.5 gm. doses on May 24, and June 7 and 21, were injected 
intravenously. There were 30 mercury inunctions about this time. At dis- 
charge on July 7 the prescribed diet was 100 gm. protein, 95 gm. carbohydrate 
(including 20 gm. bread), and 2400 calories (approximately 1.4 gm. protein and 
33 calories per kg., reduced one-seventh by the weekly fast-days). The re- 
covery of subjective health was complete, in such manner that there was no 
question of the patient's future fidelity. 

Acidosis. Ferric Chloride Reaction. — First may be noted the fact that a 
slight ferric chloride reaction was present along with glycosuria on the lax diet 
at admission, and on the carbohydrate-poor diet of Apr. 24 this cleared up com- 
pletely. It then reappeared on the second day of fasting and became heavy, 
but this was no reason for discontinuing the fast. The reaction diminished to 
traces on May 8 and 9, but the ingestion of 100 gm. carbohydrate without other 
food was unable to abolish it completely on these days. With the diminished 
carbohydrate intake and the gradual addition of fat on the succeeding days, it 
again became heavy, but showed the usual tendency to fade out, irrespective of 
diet, as the general condition improved. After becoming negative, it stiU showed 
the same tendency to reappear with fasting, being present on June 21 after a fast- 
day (but not on the fast-day itself), absent with the fast-day of June 27, and 
present on the fast-day of July 4. The trace of glycosuria which appeared on 
Jime 23 was supposedly the result of slight excitement, and, as frequently hap- 
pens, a trace of ferric chloride reaction appeared with the sugar. 

Blood Bicarbonate. — No CO2 estimations were made during the first few days. 
The low level of 45 per cent on Apr. 30 was probably the result of fasting. No 
alkali was given, and the curve tended to rise rather than fall. Particularly the 
allowance of a little carbohydrate brought it well up to normal limits on May 6. 
With undernutrition and predominantly fat diet on May 12, the CO2 was again 
down to 46.4 per cent. On the morning of May 18, following the increased diets 
of May 16 and 17, it was again within normal limits. It may be noted that this 
rise was not prevented by the febrile attacks mentioned below. On May 24, 
following the preceding fast-day, it was again barely above 45 per cent. With 
the higher diets and higher carbohydrate ration prior to discharge, the CO2 
capacity was at a high normal level. 

Ammonia.— In conformity with the absence of other signs of acidosis, the 
ammonia nitrogen on carbohydrate-poor diet on Apr. 24 was only 0.63 gm. It 
steadily rose on fasting, showing the development of acidosis, and on Apr. 30 had 
reached 2.27 gm. The 100 gm. carbohydrate on May 8 and 9 brought the ammonia 
down to a low normal level. Thereupon, with little carbohydrate, and under- 
nutrition with a predommance of fat, the ammonia rose slightly. On May 13, 
0.2 gm. salvarsan in 150 cc. saline was injected intravenously. On May 14, 
there was temperature of 100.8°F., with slight albuminuria and a few casts! 



CASE RECORDS 345 

Toward evening there was a chill with temperature of 104°, leucocyte count 
14,000, polynuclear 75 per cent; no malaria parasites; blood culture sterile; 
influenza bacillus and Pneumococcus IV in sputum. On the following days 
there was pain and swelling of the left leg from knee to ankle. By May 18, the 
temperature was down to 99.2°, and thereafter was normal. Aside from the 
hyperglycemia shown, this infectious attack made itself felt strikingly in the 
ammonia output. This climbed steeply to the astonishing figure of 5 gm. am- 
monia nitrogen on May 17, then fell abruptly as the temperature fell. Rela- 
tively low values were present with the undernutrition and fasting of May 19 
and 20. In consequence of protein-fat feeding, the ammonia rose as feeding was 
continued to nearly 3.36 gm. N on May 26 and 30. Thereafter, with increasing 
carbohydrate intake and improved general condition, the ammonia proceeded to 
fall to a permanently normal level. 

Blood Sugar. — The hyperglycemia doubtless present at admission was re- 
placed by the normal figure of 0.120 per cent as early as Apr. 27. The rise to 
0.167 per cent on Apr. 30 is one of the curious fluctuations which occur some- 
times in fasting. Hyperglycemia of 0.168 per cent was present with the febrile 
attack on May 18. Subsequent determinations showed fully normal values 
(mornings before breakfast). 

Weight and Nutrition. — The patient was obviously overnourished, and treat- 
ment consisted primarily in reducing weight and relieving the overburdened 
metabolism. The sharp fall in the weight curve during the early undernutrition 
is shown in the graphic chart. It was noted above that only benefit was felt 
subjectively, and the existing grippe infection and albuminuria both cleared up 
promptly. Even during the period of low diets the patient said he felt as if 10 
years had been subtracted from his age. He lost 10.2 kg. in hospital, but the 
weight of 72 kg. at discharge was abundant for his stature, and he stated that he 
had never felt better in his life. It is obviously bad practice to allow a diabetic 
patient to carry abnormal weight. The good prognosis of fat diabetes belongs 
to the mildness of the diabetes and not to the obesity, and the prognosis is better 
when the obesity is properly reduced. 

Subsequent History. — ^The patient took long vacation trips to Michigan and 
California, exercised heavily in walking, swimming, etc., and remained free from 
glycosuria. On Oct. 8 the diet was increased by two eggs and 20 gm. bread. The 
weight was 72.6 kg. On Jan. 1, 1916, it was the same. On Apr. 8, 1916, 25 
gm. glucose were given at 11 a.m., and specimens of urine at 12, 1, 2, and 3 p. m. 
were negative for sugar. Weight 80 kg. On Apr. 24, the patient came to the 
hospital fasting for the purpose of a glucose test. 100 gm. Merck anhydrous 
dextrose were ingested at 9:55 a.m. The record was as follows: 



346 



CHAPTER III 



Hr. 


Blood Sugar. 


Plasma Sugar. 


Urine Sugar. 




fer cent 


fer cent 




9:50 a.m. 


0.125 


0.135 





10:50 " 


0.179 


— 





11:50 " 


0.156 


0.164 


Faint. 


12:50 p.m. 


0.123 


0.110 





2:05 " 


0.083 


0.084 






Up to this time the patient had received a total of 9 intravenous injections of 
0.5 gm. salvarsan and 30 mercury inimctions. The Wassermann reaction re- 
mained consistently + + + +. With the idea that the diabetes might have 
been of luetic origin and might have been cured by the specific treatment, per- 
mission was given on the basis of this glucose test for the patient to relax his 
diet to the extent of ceasing to weigh food, and merely take the same general 
type of diet as before so as to avoid much carbohydrate. Up to June 1, 1916, 
three more doses of salvarsan had been given, also three mercurial injections 
outside this Institute. He was seen at the Institute July 14, weighing 86.2 kg.; 
i. e., a greater obesity than at the time of the first admission. He looked tired 
and overstrained. Glycosuria was present. He had not been performing urine 
tests, and showed blood sugar 0.270 per cent, plasma sugar 0.294 per cent, CO2 
capacity of plasma 62 per cent. He was instructed to resume a weighed diet of 
93 gm. protein, 75 gm. carbohdyrate, and 2300 calories, and to take measures to 
reduce his excessive weight. With swimming and other heavy exercise he lost 
2 kg. in the following week, and became free from glycosuria and ketomu^ia on 
July 20. On Jidy 21 the sugar in whole blood was 0.182 per cent, in plasma 
0.204 per cent, COz capacity 54.7 per cent. The urine has since remained nor- 
mal and the patient has retained subjective health. The management of the 
diet at home is probably not accurate, for with continuous exercise he has never 
brought his weight below 80 kg. Vigorous treatment with salvarsan and mer- 
cury has been continued under the care of a competent private practitioner, but 
the Wassermann reaction is stiU -f- -f- -|- in the serum. 

Remarks. — The case is of special interest in connection with the possible 
luetic origin of the diabetes. There has been no tendency to progress down- 
ward even though the Wassermann reaction remained strongly positive. The 
state of health was transformed by diet alone, before any antisyphUitic treatment 
was employed. If specific treatment checked the syphilitic damage, it did not 
repair it. The combined treatment did not cure the diabetes, notwithstanding 
the excellent result of the glucose test of Apr. 24. It could then have been no- 
ticed that the patient at his elevated weight showed hyperglycemia even on 
fasting, and the blood sugar curve following the dose of glucose was unduly 
high. This warning was not heeded; and with further gain of weight, without 
carbohydrate excess, the inevitable glycosuria returned in due season. 

The case was a t3rpical example of so called "spontaneous downward progress" 
when the treatment was wrong; but progress was upward when the treat- 



CASE RECORDS 347 

ment was right. The patient's treatment of himself at home is evidently not 
sufficiently stringent. He keeps his weight too high, and although he is in 
excellent subjective health and carries on his work without difficulty and the 
urine remains normal, more rigid treatment is necessary or there may ultimately 
be trouble.' 

CASE NO. 42. 

Female, age 11 yrs. American; schoolgirl. Admitted Apr. 30, 1915. 

Family History. — Patient is the only child of apparently healthy parents, with 
no heritable disease anywhere in family as far as known. 

Past History. — Measles and whooping-cough in infancy. Scarlet fever at 7 
and again at 9. No sequelae. Has been a strong, healthy, well grown child, 
though living in tenement environment. She has attended school in the usual 
grades. During the past 2 years she has been nervous, the mother stating that 
"the higher she gets in school the more nervous she gets." About the average 
indulgence in candy. A curious feature of diet is that she has never eaten vege- 
tables, not even potatoes. The food has been mostly eggs, bread, and milk. 
Appetite has been notably small and she has had to be coaxed to eat. 

Present Illness. — 3 weeks before admission polyphagia, polydipsia, and poly- 
uria began acutely. After 2 weeks she was taken to a physician who first pre- 
scribed carbohydrate-free diet with addition of milk, then as glycosuria continued 
he advised bringing her to this Institute. 

Physical Examination. — ^A thoroughly well developed and nourished, normal 
appearing girl. Tonsils protrude and show deep crypts, with pus on pressure. 
Very few small lymph nodes palpable. Reflexes normal. General examination 
fully normal. The child is a splendid physical specimen, brimming over with hfe 
and spirits. 

Treatment. — Patient was admitted at 11:45 a.m. Apr. 30, and received no 
food on that day. Castor oil was given as a laxative. The blood sugar was 
0.286 per cent at 3:30 p.m., but probably diminished rapidly, for the glycosuria 
in the mixed urine up to the next morning was only 0.3 per cent. On May 1, 
nothing was given but two eggs and 450 cc. clear soup. May 2 and 3 were fast- 
days. The glycosuria was only slight on May 1, and immediatelly cleared up, 
the whole picture being characteristic of an early, still mild stage in which glyco- 
suria and hyperglycemia had been kept up essentially by carbohydrate. On the 
other hand, the ferric chloride reaction was well marked at admission and became 
heavy on fasting. The child also vomited on the ist fast-day and was weak on 

' Continued specific treatment finally reduced the Wassermann reaction to ± . . 
At the same time continuous glycosuria gradually developed, followed within a 
few weeks (Feb., 1918) by a rather threatening infection of the right foot. This 
cleared up promptly with fasting and rest, and a more rigid dietetic regime has 
since been pursued. 



348 CHAPTER III 

the 2nd. On May 4, she received 16 gm. carbohydrate without glycosuria. 
With 40 gm. carbohydrate on May 5 in the form of green vegetables and 150 gm. 
strawberries, a trace of glycosuria appeared, increased with 60 gm. carbohydrate 
on May 6, and disappeared with a reduction of carbohydrate to 12 gm. on May 7. 
By this time the ferric chloride reaction was diminished, and a diet of eggs and 
sugar-free milk (Whiting's) was begun, with S gm. carbohydrate in the form of 
celery and asparagus. The caloric intake was below 650, and with this under- 
nutrition the ferric chloride reaction and all other signs of acidosis were cleared 
up by May 13. Traces of glycosuria were frequent, and accordingly, without 
further trouble from acidosis, the diet from May 16 to 21 was kept so low as to 
represent almost continuous fasting. Beginning May 22, the attempt was made 
to feed approximately 1200 calories daily; but glycosuria promptly appeared, and 
continued notwithstanding withdrawal of carbohydrate and a partial fast-day on 
May 27 and a complete fast-day on May 30. This being an impossible state of 
affairs, the child was brought to confess that the glycosuria was due to her stealing 
small quantities of bread. Though always a rather unmanageable patient, 
she was tractable after learning that glycosuria meant fasting, and soon became 
contented imder hospital discipline. 

On Jime 2 partial, and on June 3 complete fasting was given. Beginning 
June 4, a carbohydrate tolerance test was continued until June 26. A deceptive 
trace of glycosuria appeared with 180 gm. carbohydrate on June 17, but the 
true tolerance proved to be 260 gm. carbohydrate on June 25 and 26, in contrast 
to the 40 to 60 gm. carbohydrate which had caused glycosuria on May 5 and 6. 
The benefits of the 2 months of imdernutrition and liberal carbohydrate supply 
were now apparent in a greatly increased tolerance for mixed diets. This was 
rapidly built up, with routine weekly fast-days, and glycosuria was absent until 
the increase reached 84 gm. protein, 110 gm. carbohydrate, and 2250 calories on 
July 21. The ration was immediately reduced to a lower figure than had been 
tolerated before, nevertheless glycosuria continued for 3 days. The child was 
now clinically and subjectively entirely well, and the urine remained normal ex- 
cept for the traces of glycosuria on Aug. 19 and 20, due to stealing food. Oct. 11 
to Nov. 3, another carbohydrate test showed a tolerance of 240 gm., as compared 
with 260 gm. in June. In Nov. a diet of 75 gm. protein, 75 gm. carbohydrate, 
and 1500 calories was assimilated without glycosuria. In Dec. the attempt to 
replace part of the fat with carbohydrate, making the diet 75 gm. protein, 100 
gm. carbohydrate, and 1500 calories, was endured for about 2 weeks, then caused 
glycosuria on Dec. 15 and 16, so that the former diet with 75 gm. carbohydrate 
was resumed. She was discharged on this, after having been 232 days in 
hospital. 

Acidosis. — This was an instance of the production of acidosis by fasting. 
The tendency was already present, as shown by the ferric chloride reaction and 
slightly subnormal blood alkalinity at admission; but the nausea and weakness 
developing early in fasting were characteristic, and on the morning of May 4 



CASE RECORDS 



349 



the CO2 capacity of the plasma was found to have fallen to the ominous level of 
27 per cent. No alkali was given, but only the 16 gm. carbohydrate in green 
vegetables as mentioned. With small carbohydrate intake the CO2 capacity 
rose quickly to 44 per cent on May 6; then on a protein-fat diet of 600 calories 
with only 5 gm. carbohydrate it rose still further. On May 18, which was a 
green day with 20 gm. carbohydrate in the form of celery, asparagus, tomato, 
and cucumber, the CO2 was as high as at admission. With the carbohydrate 
tolerance test in June it reached a high normal level. It tended to fall below 
normal on the ensuing mixed diet. The tendency toward acidosis on fasting was 
displayed in the tests made on the morning of the fast-day of Sept. 12 and the fol- 
lowing morning, but the steep drop in plasma bicarbonate as a result of this 
fast was partly explainable by the lively exercise which the patient was now 
taking. The later values, with the exception of the low figure of 48.8 per cent 
on Nov. 17, were normal for a child. 

Blood Sugar. — The quick fall to normal is characteristic of an early case. 
Normal values were still present on Sept. 12 and 13, after a long period of ade- 
quate nutrition; but increase of the carbohydrate allowance from 82 to 100 gm. 
on Sept. 23 without change in the total calories resulted in a rise of blood sugar 
to 0.26 per cent on Oct. 7. There was hyperglycemia of 0.25 per cent on Oct. 
22 during the carbohydrate test. Thereafter the general tendency of the curve 
was downward. Notwithstanding the increase of carbohydrate on Nov. 30, 
which subsequently resulted in glycosuria, the analysis before breakfast on Dec. 
4 showed normal sugar in the whole blood and only slight elevation in the plasma. 
At the close of the following week, on Dec. 11, there was definite hyperglycemia, 
giving advance warning of the glycosuria which appeared on Dec. IS. 

Weight and Nutrition. — Though the patient was a growing child, undernu- 
trition was employed to obtain control of the threatening condition present when 
admitted. The degree of undernutrition thus enforced for 2 months can be 
shown as follows. The quantity of bread obtained surreptitiously was so small 
as to be negligible in this calculation. 



58 days. 



Total calories in diet 37,132 

" protein" " 1,769. 9gni. 

Animal " " " 850.3 " 

Vegetable" " " 919.6 " 

Carbohydrate" " 3,190.0 " 



Per day 

(average) 


Per day 

per kg. 


640.0 


24.0 


30 . 5 gm. 


1.13 gm 


14.6 " 


0.54 " 


15.8 " 


0.58 " 


55.0 " 


2.03 " 



The child was cross and rebellious at first because of having been spoiled at 
home, so that trouble resulted not merely from hunger but from any matters in 
which her will was thwarted. The greatest loss of weight was 3 kg. The in- 
crease of weight during the carbohydrate test in June represented the usual 
slight edema. By reason of the subsequent diets, the weight at dismissal was the 
same as at entrance. It was not learned whether any growth in stature occurred 



350 CHAPTER III 

in hospital. At discharge, with weight of 27 kg. and height of 129.8 cm., the child 
appeared splendidly developed and nourished and her strength and spirits were 
of the highest. 

The diet at discharge represented approximately 2.8 gm. protein and 56 cal- 
ories per kg., reduced by the weekly fast-days to 2.4 gm. protein and 48 calories 
average per kg. Along with this, heavy exercise had been employed and was 
evidently one reason for the failure to gain weight. The child had certainly 
gained in muscle, for her muscles were large and hard at discharge, and presum- 
ably she had lost some fat. Exercise was in the form of strenuous sports, and 
because of her strength and boisterous disposition she enjoyed these thoroughly. 

Subsequent History. — This was an instance in which more reliance had to be 
placed on the child than on the parents, for they would not control her effectively. 
Though spoiled and rebellious at first, she had become obedient and convinced of 
the necessity of remaining free from glycosuria. Though in tenement environ- 
ment, she was able to obtain the required food, and remained free from glycosuria, 
except for 1 day in Jan. with a bad cold. She continued exercise and also at- 
tended school, leading a thoroughly normal child's life except for diet. On 
Mar. 2, 1916, the height was 130.6 cm. On Apr. 18, the blood sugar was 0.156 
per cent, plasma sugar 0.164 per cent, CO2 capacity 52.6 per cent. As the urine 
was consistently normal, 150 cc. milk were added to the diet. On June 13, the 
blood sugar was 0.123 per cent, plasma sugar 0.130 per cent, CO2 capacity 52.1 
per cent. On July 17, the health and urine remained as before. The blood sugar 
was 0.192 per cent, plasma sugar 0.227 per cent, CO2 capacity 50.5 per cent. 
Weight 26.8 kg. Height 131 cm. The diet was diminished to 1400 calories 
with only 50 gm. carbohydrate, and the patient was allowed to go to the country 
until fall. In Nov. traces of glycosuria began to appear frequently, the urine and 
subjective condition having been normal up to this time. The patient was there- 
fore readmitted Nov. 17, 1916. 

Second Admission. — The weight was 27.8 kg. There was slight edema of feet, 
but the apparent physical condition was still very good, though the child was 
obviously not so strong as before. Only a trace of glycosuria was present, but 
this persisted on a diet of 60 gm. protein, 15 gm. carbohydrate, and 800 calories. 
It cleared up with 1 fast-day. A carbohydrate tolerance test was then insti- 
tuted in the usual manner, and the tolerance was found to be only 90 gm. There- 
after a diet was given consisting of '40 gm. protein, 10 gm. carbohydrate, and 
800 calories. Any attempt at an increase above this diet caused glycosuria. 
She was discharged on this diet Dec. 18, 1916, weighing 25.5 kg. On the basis of 
this weight, with allowance for the weekly fast-days, the prescribed diet repre- 
sented 1.3 gm. protein and 27 calories per kg. 

Subsequent History. — Traces of glycosuria still recurred, and on this account 
the patient was out of the hospital only a little over 2 weeks. 

Third Admission. — Jan. 4, 1917. Weight 27.5 kg., evidently explainable by 
edema, as the diet had not been high enough for gain in weight. Only a trace 



CASE RECORDS 351 

of glycosuria was present, and the prescribed diet was continued for 3 days in hos- 
pital to determine whether it resulted from violation of diet at home. The 
sugar, however, slightly increased instead of decreasing, and 2 fast-days were then 
necessary to stop it. The trace of ferric chloride reaction present at admission 
persisted on fasting, but the ammonia nitrogen, which had been 1 gm., fellto 
0.36 gm. A carbohydrate test was then given in the usual manner, and the toler- 
ance was found to be only SO gm., indicating steady downward progress. The 
blood sugar on admission was 0.332 per cent, and at the end of a fast-day following 
the carbohydrate test it was 0.176 per cent. Frequent traces of glycosuria and 
acidosis persisted on a diet of 36gm. protein, 10 gm. carbohydrate, and 750 calories. 
In Feb. the condition changed for the worse. There were gastric upsets, edema 
of face and legs', mental depression, and loss of weight and strength. The diet 
was gradually diminished to 25 gm. protein and 350 calories without carbohy- 
drate, but traces of glycosuria continued, while acidosis was absent or slight by all 
tests. There was no cough, but pain particularly with breathing appeared over 
the precordia. The temperature did not go above 98.9° F. Physical and x-ray 
examinations gave only suspicious and not positive signs in lungs. The continu- 
ance of pain made tuberculous pleurisy probable. On Feb. 27, the CO2 capacity 
of the plasma was down to 44 per cent. A trace of ferric chloride reaction re- 
turned on Mar. 5. At the beginning of Mar. the attempt to maintain sugar- 
freedom was abandoned, and heavy glycosuria was thenceforth present on a 
carbohydrate-free diet of 30 gm. protein and 450 calories. By Mar. 8, the am- 
monia nitrogen was up to 1.1 gm. The ferric chloride reaction gradually became 
heavy. By Mar. 14 the ammonia nitrogen was 1.5 gm. The CO2 capacity of 
the plasma was 18.9 per cent on that day. IS gm. sodium bicarbonate were 
given, and the CO2 capacity fell to 16.9 per cent. The patient died in diabetic 
coma on Mar. 15, 1917. 

Remarks. — The patient was received with diabetes acute and severe in type, 
but yet early and mild in degree. She was treated for 2 months with rigorous 
undernutrition, and all threatening symptoms cleared up and a high carbohydrate 
tolerance was developed. Undernutrition was then abandoned and the attempt 
was made to feed a high calory diet suitable for a normal child, while at the same 
time gain in weight was prevented by means of heavy exercise. A splendid physi- 
cal condition was attained. 

The child was kept alive for 2 years, during the greater part of which she 
enjoyed a high degree of health and led an approximately normal existence. The 
outcome shows that exercise cannot wholly replace restriction of total calories. 
While downward progress may be unavoidable with severe diabetes under the 
metabolic strain of youth and growth in children, a longer and better course in 
other children more rigidly treated is an indication that at least part of the down- 
ward progress in this case was attributable to the unduly high diet. It is better 
to make a less severe reduction in the earliest stage when so much greater benefit 
is attainable, than a more extreme reduction after downward progress has 



352 CHAPTER in 

resulted. As usual, the attempt to maintain the highest possiblelevel of vigor 
did not prevent and probably predisposed to infection. With the onset of 
tuberculosis, a quickly fatal termination in such a case was assured. 

CASE NO. 43. 

Female, xmmarried, age 27 yrs. American; nurse. Admitted May 31, 1915. 

Family History.— Fa.theT died at 70 of Bright's disease. Mother died of un- 
known cause during menopause at 45. Possible diabetes in a maternal aunt. 
Maternal grandmother died of tuberculosis. No other heritable disease known. 

Past History. — Patient has spent her life under favorable conditions in two 
southern states. In childhood, measles, mumps, whooping-cough, chicken-pox, 
diphtheria. Pneumonia at 7 and again at 17; both light. In the spring of each 
year she has had so called malarial attacks with slight fever and malaise, but 
without chills. Menstruation has been irregular. General health good. Habits 
and diet normal. 3 years ago she accidentally plunged a hj^odermic needle 
into her hand and broke off the point, which was not extracted for 24 hours. 
Severe sepsis resulted. The whole arm was swollen and blackened, and three 
incisions were made for drainage. There was delirium, and at one time her 
recovery was not expected. The hand has only partially recovered function. 
There was also albuminuria durilig the attack, and treatment with diet and 
other measures for nephritis was followed for many months. Albuminuria finally 
cleared up. 

Present Illness. — In Jan., 1915, marked polyphagia, polydipsia, and polyuria 
were noticed, and the weight fell from the usual 118 to 97 pounds. About the 
first of Mar. she concluded she had diabetes, and this was confirmed by a medical 
examination. Beginning late in Mar. she was imder treatment in hospital for 
several weeks on the von Noorden plan with green days, oatmeal days, and 
occasional fast-days. She was sugar-free during the last week, but relapsed on 
leaving hospital. Since the middle of Apr. she has been on protein-fat diet with 
addition of green vegetables, a little potato, and two slices of bread at each meal. 
Pruritus vulvae troublesome. 

Physical Examination. — ^Poorly developed, thin young woman. Pale com- 
plexion. Skin dry. Considerable loss of hair. Mouth and throat normal. A 
few barely palpable lymph nodes. Reflexes normal. Trace albuminuria. Ex- 
amination otherwise negative. 

Treatment. — On June 1, the first day in hospital, the diet was 83 gm. protein, 
5 gm. carbohydrate, and 2530 calories. The sugar excretion was 14.88 gm. On 
the next day 2071 calories were taken. June 3 and 4 were fast-days with no food 
of any kind. On June 5 and 6, 300 cc. clear soup, 150 cc. coffee, and 3550 cc. 
whisky were permitted. Glycosuria cleared up, but signs of acidosis became 
marked. On June 7, green vegetables containing 10 gm. carbohydrate produced 
prompt glycosuria. This carbohydrate was continued, and eggs, butter, and 



CASE RECORDS 353 

bacon were added to build up a diet approximating 1600 calories. Glycosuria 
diminished when the carbohydrate was halved, but did not cease until the fast- 
day of June 13. Thereafter a similar diet was tolerated up to June 21. Begin- 
ning June 22, a carbohydrate tolerance test was instituted, and ignoring insignifi- 
cant traces of glycosuria on July 5 and 8, the tolerance was reached with 230 gm. 
carbohydrate on July 17 and 18. Thereafter a mixed diet of 80 to 100 gm. pro- 
tein, 100 gm. carbohydrate, and 2200 to 2500 calories was taken, with only occa- 
sional traces of glycosuria. The weight having risen to equal that at entrance, 
another carbohydrate test was begun on Oct. 11, and the limit of tolerance was 
reached with 170 to 190 gm. carbohydrate. Mixed diet was then resumed, and 
though 2500 calories were tolerated, the permanent level, beginning Nov. 5, 
was fixed at 2000 calories. Green days with 25 gm. carbohydrate were substi- 
tuted for the previous weekly fast-days. Though glycosuria was absent, the 
carbohydrate allowance beginning Nov. 26 was diminished to 25 gm. Never- 
theless, a decided glycosuria appeared in the middle of Dec. It was then learned 
that this, and also the preceding appearances of glycosuria (Nov. 6 to 24) had been 
due to the patient's buying and eating 10 cents worth of cheese when on walks 
away from the hospital. After reduced diet and fasting (Dec. 17 to 20) the gly- 
cosuria was cleared up, and the former diet resumed on Dec. 21 without glycosuria. 
The patient was dismissed on a diet of 80 gm. protein, 25 gm. carbohydrate, 
and 1800 calories (1.92 gm. protein and 43 calories per kg., reduced by weekly 
fast-days to an average of 1.65 gm. protein and 37 calories per kg.). She felt 
well at discharge, except on fast-days, which always left her temporarily weak 
and depressed. She proposed to imdertake diabetic nursing, and was instructed 
also to continue regular exercise. 

Acidosis. — ^At admission there were no acidosis symptoms, the ferric chloride 
reaction was slight, the ammonia output was low, and the first carbon dioxide 
determinations only slightly subnormal. Acidosis was produced by fasting. The 
ferric chloride reaction promptly became heavy. Before breakfast on the morning 
of June 7 the CO2 capacity of the plasma was down to 35 per cent, and the am- 
monia nitrogen by that day had risen to 2.35 gm. Alcohol up to 350 calories had 
not prevented this acidosis. On June 8, 20 gm. sodium bicarbonate were given, 
with the low calory diet and 10 gm. carbohydrate above mentioned. The result 
was a prompt rise in CO2 and fall in ammonia. But with simple increase of pro- 
tein-fat diet without any more alkali, the CO2 capacity rose still more sharply 
to a fuUy normal level, and the ammonia output correspondingly fell. The 
acidosis was also manifested by the usual clinical symptoms of nausea, vomiting, 
and malaise; these also cleared up promptly on feeding. The CO2 capacity was 
unaccountably low on July 8, probably in consequence of undernutrition and 
exertion, while on the next day the usual high normal value was found present. 
On mixed diet the curve had descended by Sept. 12 to the lower normal limit. 
The tendency toward acidosis on fast-days persisted. Sept. 12 was a fast-day, 
and the CO2 capacity that morning was 54.8 per cent, whereas the next morning, 



354 CHAPTER III 

after 24 hours with only 300 cc. soup and 300 cc. coffee, it was down to 46.6 per 
cent; while after 3 days of feeding it was 57 per cent on the morning of Sept. 16. 
It was also within normal Hmits on Oct. 29, at the close of a carbohydrate test; 
but on the morning of Nov. 1, after the previous fast-day, it was down to 47.4 per 
cent. On the other hand, on Dec. 19 the high normal value found after fasting 
is perhaps one indication of the improved condition, notwithstanding the exist- 
ence of a positive ferric chloride reaction in the urine at that time. It is also 
worth noting that the ferric chloride reaction became negative on June 28 with 
nothing in the diet but vegetables representing 70 gm. carbohydrate. But after 
the carbohydrate test it reappeared on mixed diet in July and Aug., notwith- 
standing 100 gm. carbohydrate in the diet. Thereafter it tended to reappear, 
particularly with glycosuria. It seemingly was governed not so much by the 
carbohydrate intake as by the fat in the diet and the specific diabetic condition. 

Blood Sugar. — The hjrperglycemia found on the morning of Sept. 12 was 
promptly reduced to normal by the single fast-day. It was again unduly high 
with feeding, but showed a downward tendency. The excessive figure of 0.4 
per cent in whole blood and 0.44S per cent in plasma at the close of the carbo- 
hydrate test on Oct. 29, .with only slight glycosuria, probably indicates renal im- 
permeability, perhaps associated with the old nephritis. At the same time it 
must be borne in mind that the urine reactions are shown for the 24 hours, whereas 
the blood sugar was for the hyperglycemia during carbohydrate digestion. On the 
morning of Nov. 1, it was found that a single fast-day had again brought the 
blood sugar fully to normal. On Nov. 13, it was 0.125 per cent in whole blood and 
plasma, and was barely below 0.15 per cent on Dec. 19 in consequence of the 
recent violation of diet. 

Exercise. — ^As soon as adequate mixed diet was begun in Aug., vigorous exercise 
was inaugurated, including daily walks of 8 mUes. The strength and general 
appearance thereby improved. Glycosuria was present on Sept. 11, just before 
the routine fast-day. Exercise was then omitted, and it appeared earlier in the 
following week; namely, on Sept. 14 and IS. Without change in diet, an increase 
of exercise was ordered, and glycosuria immediately ceased and remained entirely 
absent in the subsequent weeks up to Oct. 9. Other observations concerning 
exercise, particularly the blood sugar, are given elsewhere (Chapter V). 

Emotion. — The glycosuria of Aug. 10 and 11 was apparently associated with 
crying spells. 

Weight and Nutrition. — The weight at admission was 44 kg. Some of the fluc- 
tuations in the curve, notably the rise during the carbohydrate test in July, were 
due to edema. It is noteworthy that the toleratice in Oct., after recovery of the 
original weight, was far different than at admission, but yet was lower than in 
July. It seems clear that the high diets from July to Oct. had been injurious, 
notwithstanding the use of exercise. At discharge the weight was 41.6 kg.; 
i.e., a loss of 2.4 kg. This was 12 kg. below her normal weight, and she had 
always been rather shght in figure. The above mentioned diet, prescribed at 



356 CHAPTER in 

patient never was guilty of any large violation of diet, but indulged herself in 
little things beyond permission. Glycosuria occasionally returned, and finally 
became continuous. When she began to feel rapidly worse, she returned for 
readmission on Dec. 2, 1916. 

Third Admission.— Tht weight was 39 kg., partly edema. No acute symp- 
toms were present, but there had been a perceptible loss in strength. With 3 
days of fasting, sugar and ferric chloride reactions became negative. The diet 
was then built up in the usual maimer, and the tolerance was found very low. 
The limit was approximately 1000 to 1100 calories with 50 gm. protem and no 
carbohydrate, and with the usual weekly fast-days. A considerable part of 
this long period in hospital was occupied with tests with fat feeding, some of 
which are described elsewhere (Chapter VI). On the very low diet the weight 
has fallen to about 33 kg. The strength also is diminished, so that the patient 
is now a confirmed invahd, able to be up and about, but not fit for work or for an 
independent existence. She has remained in the hospital iip to the present. 

Remarks. — The record of this patient during and following the first hospital 
period confirms the fact that exercise cannot atone for an unduly high diet 
The essential reasons for her downward progress have been the almost per- 
petual, slight overstepping of diet, and the frequent colds and grippe. She has 
reached the point where nothing but a hard struggle for the bare maintenance of 
Ufe is possible. With continuous hyperglycemia not tending to diminish, a slight 
continuous overstrain of the pancreatic function may be assumed, and down- 
ward progress may be expected imder such conditions even in the absence of in- 
discretions or compHcations. The only hope Hes in treatment radical enough 
to relieve the overstrain if possible. The later results wUl show whether down- 
ward progress can thus be checked at such an extreme stage. 

CASE NO. 44. 

Male, married, age 33 yrs. American; electrician. Admitted July 3, 1915. 

Family History. — Parents hved to old age. Wife and three children of patient 
are well. One aunt died of cancer of the nose. History otherwise negative. 

Past ffwtory.— Diphtheria at 4. Frequent colds m head but no cough or sore 
throat. Gonorrhea 11 years ago. Syphihs denied. Has worked in electrical 
power house for past 15 years, for past 3 years as switchboard attendant. Mod- 
erately nervous and excitable. No alcohol except occasional glass of beer. 
Smokes considerably. Four or five cups of tea or coffee daily. Not a heavy 
eater in general, but a lover of sweets. Highest weight 170 pounds, average 165 
pounds clothed. 

Present Illness. — ^Headaches and lassitude began about a year ago. 5 months 
ago pleurisy with chills, cough, and bloody expectoration confined him to bed 
for 10 days. Weight has been steadily lost, and there have been night sweats for 
week preceding admission. Polydipsia and polyuria began shortly after the 



CASE RECORDS 357 

pleurisy. A physician then diagnosed diabetes. In addition to medicines, he was 
given a diet restricted to protein-fat foods with gluten bread and such vege- 
tables as grow above the ground. He continued to lose steadily; impaired hear- 
ing, numbness of hands and feet, cramps in legs at night, nervousness, and 
irritability have been present. 

Physical Examination— Height 175 cm. A fairly developed, moderately 
emaciated man without acute symptoms. Slight pyorrhea. Many teeth miss- 
ing. Tonsils not enlarged. Slight lymph node enlargements. Reflexes normal. 
Blood pressure 90 systolic, 62 diastolic. Wassermann negative. Examination 
otherwise negative. 

Treatment.— Jinmig the first few days in hospital, glycosuria and ketonuria 
were heavy on a diet of 2100 to 2400 calories with S gm. carbohydrate. The in- 
crease of carbohydrate to 40 gm. on July 7 made little difference. On July 8, 
only breakfast was given, and glycosuria cleared up during the day. 3 fast-days 
were then imposed nevertheless, followed by a carbohydrate period. An intake 
of 340 gm. carbohydrate in the form of green vegetables was reached without 
glycosuria. The ferric chloride reaction meanwhile became negative. After a 
fast-day on Aug. 1, the diet for 3 days was limited to potato, and 200 gm. carbo- 
hydrate were taken in this form without glycosuria. A mixed diet was then 
given, consisting of 100 gm. protein, 100 gm. carbohydrate, and 2600 calories. 
Ferric chloride reactions promptly appeared, and persisted notwithstanding in- 
crease of catbohydrate to 285 gm. on Aug. 21. The diet on this day also con- 
tained 130 gm. protein and 3100 calories. Of this carbohydrate, 40 gm. were in 
the form of bread and 100 gm. in the form of potatoes. The patient was dis- 
charged on Aug. 23, weighing 58.6 kg., on a prescribed diet of 115 gm. protein, 
160 gm. carbohydrate, and 2700 calories (almost 2 gm. protein and 50 calories 
per kg., reduced one-seventh by weekly fast-days). 

Acidosis. — The CO2 capacity of the plasma was sUghtly below normal, and rose 
steadUy under treatment without the aid of alkali. The most interesting feature 
from the standpoint of acidosis pertained to the ferric chloride reaction, for al- 
though this became negative on a solely vegetable diet, it reappeared on a liberal 
mixed diet, notwithstanding an ingestion of carbohydrate theoretically abundant 
to prevent all acidosis. 

Subsequent History. — The patient resimied his regular work, and maintained 
health and normal urine. On Oct. 5, both sugar and ferric chloride reactions 
were absent from the urine, and the sugar in whole blood was 0.102 per cent, in 
plasma 0.110 per cent, weight 61 kg. In addition to his regular work of 8 hoiurs 
a day he was making extra money and at the same time obtaining exercise by 
canvassing several hours daily. On Dec. 27, the patient reported at the Insti- 
tute with temperature of 99.2° F., after having had grippe and precordial pain for 
10 days. Acidosis remained absent and he had continued his regular work. The 
excessive diet was reduced to 97 gm. protein and 2170 calories. The grippe 
cleared up promptly, and later examinations showed lungs and urine normal. 



358 CHAPTER m 

Secoftd Admission.— On Apr. 26, 1917, the patient was readmitted on account 
of lobar pneumonia (Pneumococcus Type IV). Physical signs and radiograms 
indicated consoUdation of right middle lobe. The temperature on adm'ssion 
was 101°F., rose the next day to 104°, on Apr. 28 reached the maximum of 105.6°, 
was still as high as 105.2° on Apr. 29, and fell by crisis to normal the next day. 
Liquid diet was given, largely milk, containing as high as 40 gm. carbohydrate. ^ 

The course of the pneumonia was uneventful, and neither glycosuria nor acidosis 
appeared. The patient was transferred from the pneiunonia to the diabetic serv- 
ice on May 5. He convalesced uneventfully, and was discharged May 28 on a 
diet of 100 gm. protein, 80 gm. carbohydrate, and 2250 calories. Weight 59.2 kg. 

Subsequent History.— On June 19, the patient caught cold and also lost his 
temper in a dispute. Rather heavy glycosuria appeared promptly, but disap- 
peared on omitting four meals. On resinning full diet glycosxu-ia returned, and 
ceased with another fast-day. The patient then reduced h s diet and reported 
on July 2, having been sugar-free s'nce the attack. The diet was ordered di- 
minished to 80 gm. protein, 60 gm. carbohydrate, and 2000 calories. On this he 
has since remained shghtly himgry but free from symptoms and feeling strong 
and well. In July, 1917, the weight was 61.9 kg., the blood sugar during digestion 
0.112 per cent, CO2 capacity 60.2 per cent. 

Remarks. — ^The diabetes was essentially mild, and it is hoped that it may be 
kept so. The most noteworthy feature is the wholly uneventful manner in which 
the patient passed through an attack of pneumonia of moderate severity. The 
absence of diabetic symptoms during this time may be attributed chiefly to the 
very low diet given during the period of active infection. Permanent injury 
of the tolerance was thus apparently prevented. Notwithstanding the excellent 
condition and the normal blood sugar, the outbreak in June shows that the latent 
diabetes must stiU be guarded against, doubtless throughout the patient's life, 
though improvement may perhaps continue with advancing years. On the 
other hand, the age is such as to threaten serious consequences if the condition is 
not held in check. The patient is now on a well balanced diet, which may be ex- 
pected at least to delay any downward progress if it does not prevent it altogether. 



CASE NO. 45. 

Male, age 6 yrs. American Jew. Admitted Sept. 1, 1915. 

Family History.— Pa.Tents and two brothers of patient (aged 9 and 11) are en- 
tirely well and free from glycosuria, though shghtly obese. No diabetes in 
mother's family, but her mother died of cancer at 53. The father's family his- 
tory is negative on his mother's side, but diabetic on his father's side; i.e., a 
great grandmother died at 76 of diabetes, and the father and an uncle of the 
present patient's father are living and have diabetes. No tuberculosis, syphilis, 
Bright's disease, goiter, etc., known. 



CASE RECORDS 359 

Past History. — Normal delivery. No childhood diseases; never sick a day. 
Always big and plump, but not obese. Never nervous. Has never gone to 
school but received a little instruction from a governess. He has been bright 
and quick to learn, and has spent nearly all his time playing, automobUing, or in 
other active recreations. Appetite always large, and he has eaten much cake, 
candy, ice cream, and other sweets. 

Present Illness. — ^About Nov. 20, 1914, polyuria and loss of weight were no- 
ticed. A physician prescribed medicine without examining the urine. Another 
physician a few days later discovered glycosuria, and two eminent consultants 
were called. A repetition of oatmeal and green days was employed according 
to the von Noorden plan, and the patient with difficulty was made free from 
glycosuria, but acetonuria persisted. Last Mar. there was an attack of grippe, 
with otitis media requiring paracentesis, which was performed without anesthesia. 
The patient is said to have become completely comatose; he was treated with 
fasting and rectal drip, recovered from this attack, and became sugar-free on a 
diet of Whiting's milk and thrice cooked vegetables. A little carbohydrate was 
later added, but traces of acetone continued. During the past summer, at the 
parents' summer home, the control was too lax to prevent violations of diet, with 
the result that on July 10 the patient suddenly fell out of his chair at table. He 
was then brought to New York and placed imder the care of one of the advocates 
of treatment with lactic acid bacilli. A fuU caloric diet was given with restricted 
carbohydrate during this treatment, and also sodium bicarbonate, from one to 
six heaping teaspoonfuls daily. There was steady loss of weight and strength. 
For 7 weeks past the patient has been confined to bed or chair, unable to stand 
because of weakness; for past several days he has been too weak to sit up. Dur- 
ing this time apathy and stupor have been increasing, but he is not quite in 
coma. Greater edema than that now present is said to have occurred from bi- 
carbonate in the past. The weight before onset of diabetes was 47 pounds; be- 
fore the present bicarbonate edema, it was 36 pounds. Meantime a long series of 
urinalysis reports from a commercial laboratory, exhibited by the father, showed 
steady improvement under the lactic acid treatment, the glycosuria being dimin- 
ished from heavy to slight and the acidosis having disappeared. The practi- 
tioner in charge blamed the laboratory for the mistake, but had been administer- 
ing sodium bicarbonate in maximum doses rectaUy as well as orally. An incon- 
sistency on the part of the laboratory was that their reports showed acid reac- 
tions of the urine with alleged negative ferric chloride reactions imder this 
treatment. 

Physical Examination. — Patient stiU shows signs of having been a splendidly 
developed, handsome child. He is now stuporous, and questions must be re- 
peated several times before a response is obtained. Complexion pasty. High 
degree of general anasarca; deep pitting of extremities on pressure, and fingers or 
bed clothing leave marks all over the body. EyeUds are swelled nearly shut. 
Intraocular pressure very low. Mucous membranes very red; tongue coated; 



360 CHAPTER in 

gums swollen and spongy and bleed easily. Throat not examined because of 
mental condition and edema. No gland enlargements made out. Left chest 
hjrperresonant. Right side shows everywhere flatness and other signs of a 
large pleural effusion. Systolic blood pressure approximately 62. Marked 
tympanites in abdomen, and movable dulness in flanks. Both testicles in 
scrotum, partly obscured by fluid which swells scrotum to about the size of a 
large apple. Knee and Achilles jerks not obtainable. Over the sacrum an area 
of dusky redness, as large as a man's hand, seems almost ready to slough. Tem- 
perature 97.4; pulse 66; respiration 16, without dyspnea. 

Treatment. — (No graphic chart.) The patient was too weak to move himself 
in bed, and the nurses were instructed to turn him at intervals with a view to 
avoiding pressure sores and h)rpostatic pneumonia. Fasting was begun with 
very small doses of whisky. Notwithstanding the huge bicarbonate edema, the 
previous reports of acid urine were confirmed, and in the presence of incipient 
coma, fear was entertained of stopping bicarbonate suddenly, or using any strong 
diuretic which might alter the water balance in imknown manner. Accord- 
ingly, on the 1st day 10 gm. sodium bicarbonate, 16 gm. calcium carbonate, and 
4 gm. magnesium oxide were given, and on the next day 20 gm. each of sodium 
bicarbonate and calcium carbonate, also 1 cc. aromatic cascara. Satisfactory 
laxative action was obtained, and there was neither nausea nor diarrhea. The 
tympanites was reheved. The attempt was made to force fluids, and 3850 cc. 
water were given on Sept. 2, but the total urinary output was only 1425 cc. It 
was evident that the child was unable to dispose of his fluid, and this fact was 
further evidenced by the gain of 2.6 kg. weight, with evident increase of edema. 
Strength did not improve, as it frequently does on fasting. On the contrary, 
there was a perceptible increase of weakness, though the mental condition decid- 
edly improved. Both glycosuria and ketonuria were rapidly diminishing. Be- 
ginning Sept. 3, no alkali was used, and water was suppUed only for thirst. By 
Sept. 5 glycosuria was absent, and on the next day the ferric chloride reaction 
was entirely negative. The child was mentally bright, and seemed in no imme- 
diate danger in regard to strength. Green vegetables representing 3.3 gm. car- 
bohydrate were eaten with reUsh, and it was planned to begin protein feeding the 
following day, with encouraging prospects. Edema was beginnmg to subside, as 
shown by the falling weight; but albuminuria, which had been absent on admis- 
sion, seemed to develop as the urine turned alkaline; casts were not foxmd. Dur- 
ing the night of Sept. 6-7, the strength suddenly collapsed altogether. The resi- 
dent physician, immediately called, gave a saline hypodermoclysis, which was 
absorbed but had no perceptible effect. When seen at 4:30 a.m., the child was 
cold in spite of being surrounded with hot water bottles; temperature down to 
95.8°; pulse 60, barely perceptible; respiration 16 to 20; completely unconscious, 
without eye reflex; rectal sphincter completely relaxed. 10 gm. levulose m 100 cc. 
water were immediately given by stomach tube, and another 10 gm. in 100 cc. 
saline subcutaneously. The condition seemed to improve sHghtly, but con- 



CASE RECORDS 361 

sciousness did not return. At 6:50 a.m. another hypodermoclysis was given of 
250 cc. saline containing 20 gm. levulose. Half an hour after this, when asked if 
he was hungry, the child answered yes. He swallowed 50 cc. bouillon containing 
2 gm. ereptone. During the day six eggs, SO gm. butter, and 700 cc. soup were 
taken with relish, also 20 cc. whisky. A similar diet was given on Sept. 8. 
The child seemed to be rapidly gaining strength; but diarrhea was present, sup- 
posedly due to the levulose and ereptone, and bismuth was given for this. By 
Sept. 9, the stools had become frequent, badly digested, and very putrid in odor. 
Tympanites had returned. In place of the former subnormal temperature there 
was now fever of 101.8°. The blood pressure could now be definitely determined 
at 85 systolic and 68 diastolic. The patient now moved his arms and legs volun- 
tarily, but had not become able to turn his body. On account of the apparent 
putrefactive intestinal condition, and the impossibility of employing fasting in 
view of the former collapse, it was decided to try oatmeal. Therefore, the former 
egg diet was stopped after breakfast. A dose of 10 cc. castor oil was given; 16 
cc. whisky, 60 gm. oatmeal, and 200 cc. clear soup constituted the diet for this 
day. The tympanites and diarrhea were not relieved; stools became frothy as 
well as foul smelling. Heavy glycosuria appeared immediately, as shown in Table 
XII, and with it a moderate ferric chloride reaction. Stupor and Kussmaul 
dyspnea came on rapidly. As the oatmeal had failed so completely, it was or- 
dered stopped at evening, and 10 cc. more castor oU were given. Between 9 
and 10 p.m., a 250 cc. cylinder containing 25 cc. 3 per cent sodium citrate solu- 
tion was filled with blood from the patient's father. A vein was exposed in the 
patient's arm, the operation eliciting no sign of consciousness, and the blood was 
■allowed to flow in. It was hoped by means of the transfusion to contribute a little 
strength to tide over the fasting necessary as the only hope for clearing up the 
coma. No inmiediate change was perceptible except a slight improvement in 
pulse. On Sept. 10, the temperature had become normal and the patient could 
be roused. Toward evening he wakened spontaneously and began to cry for 
food. 75 cc. clear soup were given. Edema of both face and feet became more 
marked. On Sept. 11, the child became unconscious in a different manner, 
with weak pulse and feeble Cheyne-Stokes breathing. Another transfusion of 
150 cc. citrated blood from the father was given; a hypodermoclysis of 200 cc. 
saline containing 10 gm. levulose; and by stomach tube 6 cc. whisky, 10 gm. 
levulose, and 140 cc. Whiting's milk, from which the cream had been removed 
by centrifugation. The temperature was normal, and the picture was one of 
intoxication, different from the previous hunger collapse or diabetic coma. Eggs 
and whisky were given by stomach tube during the day, making a total diet of 
40 gm. protein and 500 calories. The putrid smelling diarrhea returned, and 
death occurred with weakness, imconsciousness, and Cheyne-Stokes breathing at 
5:30 p.m. 

Acidosis. — ^The excessive use of bicarbonate, guided only by the urinary reac- 
tions, had produced not only extreme anasarca but a decided alkalosis. Prob- 



362 CHAPTER in 

ably this and the renal impermeability formed a vicious circle, each making the 
other worse. The lack of paralleUsm between urine and blood is illustrated by 
the acid urine of Sept. 9, with the highest plasma alkalinity of the series. The 
value of the direct determination of the plasma bicarbonate is thus illustrated. 
The only other indication that no more alkali was needed was given by the low 
ammonia values. These are of interest as evidence that the ammonia forma- 
tion of diabetic acidosis is due entirely to acid and not to any toxic perversion of 
protein metabolism. On the other hand, the strict independence of coma and 
acid intoxication is shown by the beginning of dialaetic coma, typical in every- 
thing except hyperpnea, observed on two occasions (at admission and Sept. 9) 
even with abnormally high plasma alkalinity. The effect of oatmeal on Sept. 9 
is also remarkable, for it increased the ketonuria, raised the plasma bicarbonate 
from 67.8 to 84.9 vol. per cent, and brought on prompt coma. Clinically, 
therefore, it aggravated both the diabetes and the intoxication, irrespective of 
chemical findings. It is interesting that such administration of carbohydrate 
with reduction of fat should have had this effect, illustrating the fact that coma 
is generally treated more safely and effectively with fasting than with carbo- 
hydrate. The acidosis caused by oatmeal cleared up on fasting, and the urine 
at death was free from both sugar and ferric chloride reactions. The relatively 
low output of acetone bodies may be explained by the renal impermeability, 
which doubtless favored retention. Neither qualitative nor quantitative tests 
for acetone bodies in the blood were made, but the clinical picture indicated 
that death was not due to acidosis. 

Lipemia. — The blood at admission showed one of the most intense grades of 
lipemia observed in this series. Analyses were not possible, and judgment is- 
based on the thick, creamy appearance of the plasma. The lipemia showed no 
perceptible diminution up to Sept. 9, but on Sept. 11, after transfusion on Sept. 
10, the. plasma was perfectly clear. It was unfortunate that the effect of the 
transfusion was not observed in this connection. 

Levulose. — The patient had tolerated 3.3 gm. carbohydrate on Sept. 4. The 
glucose tolerance in such a case must necessarily be close to zero. Nevertheless, 
40 gm. levulose on Sept. 7 were assimilated without a trace of glycosuria. The 
most remarkable feature was the clinical transformation wrought by the levu- 
lose — a patient apparently dying restored in strength and consciousness within a 
few hours. As saline h5T5odermoclysis had previously failed, this effect must be 
attributed to the levulose and not to the fluid given with it. It is of interest 
that the quantity of carbohydrate in the form of levulose was almost identical with 
that given in oatmeal on Sept. 9. The contrast between the excellent assimi- 
lation of levulose and the prompt glycosuria and ketonuria from oatmeal is 
striking. 

Transfusion. — This was performed for the purpose of improving strength, and 
not with the idea of conveying any special substances curative of either the dia- 
betes or the acidosis. The facts pertaining to this, as also other special features 
of the case are given in Table XIII. 



CASE RECORDS 363 

The analyses of the father's blood immediately preceding the two transfusions 
were as follows: 

On Sept. 9, blood sugar 0.1 per cent, plasma sugar 0.091 per cent, corpuscle 
sugar analyzed 0.125 per cent, calculated 0.114 per cent. Hemoglobin (Fleischl- 
Miescher) 104 per cent. Corpuscles (hematocrit) 42 per cent. CO2 capacity of 
plasma 56.4 per cent. 

On Sept. 11, blood sugar 0.115 per cent, plasma sugar 0.137 per cent, corpuscle 
sugar analyzed 0.097 per cent, calculated 0.083 per cent. Hemoglobin 95 per 
cent. Corpuscles (hematocrit) 40 per cent. CO2 capacity of plasma 52.8 per 
cent. The high sugar and low CO2 are explainable by the anxiety and haste of 
the father when called to the hospital. 

The purpose of improving strength was accomplished. No specific benefit to 
the diabetic condition was perceptible from the transfusion, also there was no 
indication of harm. 

Sugar Permeability of Corpuscles. — As